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NEWARSNational Disease Surveillance and
Epidemiology Unit (NADSAE)
Royal Centre for Disease Control
2018 Revised NEWARS guideline
NEWARS
National Disease Surveillance and Epidemiology Unit (NADSAE)
Royal Centre for Disease Control
2018 Revised NEWARS guideline
All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means including photocopying, recording, or information storage and retrieval without prior permission in writing from Royal Centre for Disease Control.
ISBN: 978-99936-947-7-9
Give feedback on the book at:
www.rcdc.gov.bt
Printed in Bhutan
Page 1 of 144
National Early Warning, Alert & Response Surveillance
Preface
Bhutan has made considerable progress in preventing, controlling and eliminating important communicable diseases. However, the threat from emerging and re-emerging infectious diseases particularly zoonotic origin remain public health concern because of close interaction between human, domestic and wild animals. Further, chemicals and environmental related hazards are also public health concern. To detect emergence or incursion of new diseases or pathogens in time, a sound disease surveillance system is critical. High quality surveillance is also essential to determine disease burden, trend, seasonality to facilitate evidence based policy decision and intervention. Surveillance also helps in detecting early warning alerts for any events to response efficiently and develop preparedness plans.
Prior to 2009, the country had no systematic disease surveillance system. The Royal Center for Disease Control (RCDC) then known as the Public Health Laboratory established the notifiable diseases surveillance system (NDSS) for priority diseases of national concern and developed first edition of national notifiable disease surveillance guideline in 2010. The guideline was revised as 2nd edition in 2012 to incorporate web based reporting. In 2014, the NDSS guideline was revised to incorporate event-based surveillance (EBS) and renamed as “National Early Warning Alert and Response
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Surveillance (NEWARS)”.
The 2nd revision of NEWARS was deemed necessary to update various components of the guideline including the list of notifiable diseases and syndromes, case definitions and also incorporate electronic based NEWARS reporting through web-based and mobile short message service (SMS) which was developed and implemented in 2016. This 2nd edition is expected to help healthcare professionals and relevant stakeholders in implementing NEWARS effectively and efficiently to meets its objectives.
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National Early Warning, Alert & Response Surveillance
Foreword
The Royal Center for Disease Control (RCDC) developed the first edition of National Notifiable Disease Surveillance (NNDS) guideline in 2010 and revised in 2012 to incorporate web based electronic reporting system. Subsequently, NNSD was reviewed and revised in 2014 as “National Early Warning Alert and Response Surveillance (NEWARS)” with incorporation of mobile short message service SMS and redesigned web based reporting.
This 2nd revision of NEWARS was necessary to update the various components of the guideline including the list of notifiable diseases and syndromes, case definitions and include electronic based reporting system for user guidance and reference.
The Ministry of Health would like to acknowledge all healthcare professionals, policy makers and relevant stakeholders for strong support in implementing the NEWARS successfully and we look forward for your continuous support and cooperation in implementation this revised NEWARS guideline.
(Dr. Ugyen Dophu)SECRETARYMinistry of Health
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Acknowledgment
Royal Centre for Disease Control (RCDC) would like to express deepest appreciation to all contributors who have developed 1st edition of National Early Warning Alert and Response Surveillance guideline. We are indebted for constant support and guidance rendered by the Dr. Karma Lhazeen, Director of Department of Public Health in completing 2nd edition of NEWARS guideline on time. Special thanks go to the healthcare professionals serving at various healthcare centers for providing valuable feedbacks during evaluation of NEWARS which were useful for revision of this guideline.
Dr. Sonam Wangchuk (M.Sc, PhD), Head, RCDC 1
Ms. Sonam Peldon (M.Sc Immunology), Dy. Chief Laboratory Officer1
Mr. Tshering Dorji (MBiotech, Food Microbiology), Dy. Chief Laboratory Officer1
Mr. Tsheten (MPH), Senior Laboratory Officer1
Mr. Thinley Jamtsho (B.Tech IT), Sr. ICT Officer1
Mr. Govinda Ghimeray (DIMS), ICT Technical Associate II 1
Mr. Jit Bahadur Darnal (CO/FETP), Clinical Officer1
1 Royal Center for Disease Control, Department of Public Health,, Ministry of Health
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National Early Warning, Alert & Response Surveillance
List of abbreviations
ABD Acute Bloody Diarrhoea
AES Acute Encephalitis Syndrome
AFP Acute Flaccid Paralysis
ARI Acute Respiratory Infection
AWD Acute Watery Diarrhoea
ANT Anthrax
AFP Acute Flaccid Paralysis
AJS Acute Jaundice Syndrome
AHF Acute Haemorrhagic Fever
BHU Basic Health Unit
BMG Bacterial Meningitis
CDD Communicable Disease Division
CDC Centers for Disease Control and Prevention
CRS Congenital Rubella Syndrome
DHO District Health Office
DoPH Department of Public Health
DHF Dengue haemorrhagic fever
DPT Diphtheria, pertussis, tetanus
DSS Dengue shock syndrome
HAV Hepatitis A virus
HBV Hepatitis B virus
HCV Hepatitis C virus
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HDV Hepatitis D virus
FWR Fever with Rashes
FDP Food Poisoning
EBS Event-Based Surveillance
ER Emergency Room
IBS Indicator Based Surveillance
ICD-10: International Classification of DiseasesICT Information & Communication TechnologyIHR International Health Regulation
ILI Influenza like Illness
JE Japanese encephalitis
MoH Ministry of Health
MUM Mumps
NADSAE National Disease Surveillance & Epidemiology
NEWARS National Early Warning, Alert & Response Surveillance
OPD Outpatient Department
PHEIC Public Health Event of International Concern
PTS Pertusis
RKT Rickettsioses
SARS Severe Acute Respiratory Syndrome
TPF Typhoid/paratyphoid Fever
SFP Surveillance Focal Point
WHO World Health Organization
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Table of Contents1. Preface.........................................................2. Forward........................................................3. Acknowledgment..........................................4. List of Abbreviations.....................................5. Target Users.................................................6. Goal of guideline..........................................7. Core functions of NEWARS system.............8. Roles and responsibilities............................9. National Notifiable Disease Surveillance System.........................................................10. What is a Notifiable Disease Surveillance 11. System?.......................................................12. Criteria for identifying a disease or syndrome as a National notifiable disease or syndrome.................................................13. Sources of data for notifiable disease surveillance..................................................14. Bhutan notifiable diseases or syndromes list and case definitions................................15. How the national notifiable disease surveillance system (NDSS) works..............16. Identifying diseases and syndromes............17. Preparing Report (Data Collection, Collation and Reporting)..............................18. How to report weekly notifiable diseases or syndrome.................................................19. Immediately notifiable disease.....................20. How to report immediately notifiable diseases or syndrome?................................
134511111217
25
25
25
25
25
3636
36
3739
39
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21. What is an Event-based Surveillance?........ 22. What are the events of public health concern.........................................................23. Sources of events Information and reportable events.........................................24. Event information collection and reporting...25. Practical guide to using NEWARS information system.......................................26. User Registration..........................................27. SMS System.................................................28. Adding Second Mobile Number...................29. Change Mobile Number...............................30. Change Password/Password Reset............31. Request Health Center Change...................32. Check Dates for Epidemiological Week Number.........................................................33. Check Reporting Deadline...........................34. Check for NEWARS Support Team..............35. Check Weekly Disease List..........................36. Submit Weekly Report.................................37. Submit Zero Report......................................38. Check Immediate Reporting Disease/ syndromes List.............................................39. Submit Immediate Report ............................40. Submit Event Report....................................41. Update Event Report Cases/Deaths............42. Delete Weekly Report..................................43. Delete Immediate Report.............................
41
42
4446
66668587888989
909191929393
949595969797
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National Early Warning, Alert & Response Surveillance
National Early Warning, Alert and Response Surveillance
System
National Early Warning, Alert & Response Surveillance
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1. What is Surveillance?
Surveillance by definition is the ongoing systematic health related data collection, collation, analysis, and interpretation for use in planning, implementing, monitoring, and evaluating public health policies and practices.
1.1 Why to conduct Disease surveillance?
Disease surveillance system serves two key functions; early warning of potential threats to public health including emergence of new disease or pathogens and monitoring of national public health programmes progress and achievement towards prevention, control, elimination and eradication goals for various disease of national public health concern.
The early warning functions of surveillance are fundamental for national, regional and global health security. Recent outbreaks such as the severe acute respiratory syndrome (SARS) and avian influenza, demonstrate the importance of effective national surveillance and response systems. The International Health Regulations (IHR) 2005 underscore the commitment to the goal of global security and require all Member States to establish and implement effective surveillance and response systems to detect and contain public health threats of national and international concern.
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National Early Warning, Alert & Response Surveillance
The monitoring of national public health programmes encompasses a variety of global, regional and national goals and targets such as control, elimination and eradication. Surveillance systems also serve to monitor trends of endemic diseases, and progress towards disease prevention, and control indicators and targets of national public health programmes.
1.2 What is National Early Warning Alert Response Surveillance?
The National Early Warning Alert and Response Surveillance (NEWARS) was introduced in 2014 as the national surveillance and response system for various priority diseases or syndromes of public health concern for early detection and efficiently response .
The 1st edition NEWARS was developed to replace previous National Notifiable Diseases Surveillance introduced in 2010 which was indicator based surveillance. The revision of the first edition NEWARS guideline was deemed necessary, as in the guideline required incorporation of additional information with the introduction of electronic web-based and mobile SMS reporting system for NEWARS. The 2nd edition of NEWARS guideline contains user module for electronic web-based and mobile SMS reporting to guide users for self-learning and implement NEWARS without having to wait for trainings.
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1.3 Who are NEWARS users?
This guideline is intended to provide ready reference and practical assistance in implementing NEWARS. The target audiences include Surveillance Focal Points (SFP), clinicians, nurses, laboratory staffs and other relevant healthcare professionals involved in the surveillance, District Health Officers (DHO) and National Program Officers (NPO).
1.4 What is the purpose of NEWARS guideline?
The purpose of having guideline is explain the procedure in conducting the NEWARS and uniform implementation starting from data collection, collation, reporting, analyzing, interpreting and take action to achieve quality surveillance. Further, NEWARS guideline also explains the roles and responsibilities of healthcare professionals working at all levels of health facilities including village health workers working in the community.
2. What are Objectives of NEWARS?
NEWARS has following objectives:
1. To prevent or minimize morbidity and mortality of diseases through:
• Monitoring trends of endemic diseases
• Early warning and detection of
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National Early Warning, Alert & Response Surveillance
outbreaks/events in timely manner
• Providing an adequate and timely response
• Disease burden estimation and risk factor identification
2. To monitoring effectiveness of control programs through:
• Evaluation of national programmes interventions
• Resource prioritization and mobilization
3. Stimulate research on national priority diseases
The NEWARS is supplemented by sentinel surveillance like the influenza-like Illness surveillance, acute undifferentiated fever illness surveillance, measles and rubella surveillance, acute encephalitis syndrome surveillance, diarrhea surveillance, food-borne illness surveillance, etc which collects more information on diseases, risk factors and identify etiologic agents.
3. Core functions of NEWARS system
The core functions include case detection, registration, confirmation, reporting, data analysis and interpretation, share feedback and initiate public health action. The feedbacks are disseminated
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as reports and bulletin to the data providers, stakeholders and decision-makers.
3.1 Case detection
Case detection is the process of identifying cases (listed notifiable diseases and syndromes) and suspect outbreaks as per case definition in the Basic Health Units, Hospitals, Regional Referral Hospitals and National Referral Hospital.
3.2 Case registration
Case registration is the process of recording the cases identified. This requires a standardized register or forms to record minimal data elements on notifiable diseases, and syndromes required by NEWARS guideline.
3.3 Case confirmation
Case/outbreak confirmation refers to laboratory confirmation and epidemiological link to confirm case. Case confirmation is enhanced through collection of quality of specimens from detected cases, storage and transportation through samples referral system, networking and partnerships.
3.4 Reporting
Reporting is the process by which surveillance data collected through standard case investigation form or records are reported through formal reporting mechanism from the point of generation to concern agency.
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3.5 Data analysis and interpretation
Surveillance data should be analyzed routinely and interpreted for use in public health actions. Appropriate “alert” or “epidemic” threshold values for diseases of epidemic potential can be calculated and use for monitoring.
3.6 Epidemic preparedness
Epidemic preparedness refers to the existing level of preparedness for potential epidemics which includes availability of preparedness plans, stockpiling of medicines, consumables like reagents, PPE, designation of isolation facilities, setting aside of resources for outbreak response.
3.7 Response and control
Surveillance information should be used for appropriate public health response and control by healthcare professionals and policy makers. For an early warning system response, the capacity to respond outbreaks and emerging public health threats needs to be assessed periodically and scale-up. This can be done following a major outbreak response and containment to document the quality and impact of public health response and control.
3.8 Feedback
Feedback is an important end product of NEWARS which is shared in form of report, newsletter and bulletins. The findings in feedback should
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be translated in action into practices, planning interventions and policy discussion.
1. Attributes of NEWARS System
NEWARS constitute indicator-based surveillance (IBS) and event-based surveillance (EBS). Indicator-based surveillance involves reporting of cases and deaths of 11 weekly and 15 immediately reportable diseases and syndromes seen at health centers as per the case definitions by healthcare professionals. Weekly reportable diseases and syndromes should reported every MONDAY and TUESDAY whereas immediately reportable are reported immediately as and when cases are detected in NEWARS information system monitor by the National Disease Surveillance and Epidemiology (NADSAE) Unit at RCDC .
Event-based Surveillance involves ad-hoc reporting of any ‘unusual’ event, cluster of cases, death or healthcare professionals suspect outbreak. It should be reported IMMEDIATELY by healthcare professionals including other stakeholders like public, media, civil organizations, NGOs, etc. in NEWARS information system or to the National Disease Surveillance and Epidemiology (NADSAE) Unit at RCDC or health centers who in turn report to NADSAE.
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National Early Warning, Alert & Response Surveillance
Tabl
e 1.
The
mai
n fe
atur
es o
f IB
S a
nd E
BS
Feat
ures
Indi
cato
r-ba
sed
Surv
eilla
nce
Even
t-bas
ed s
urve
illan
ce
Dis
ease
or S
yndr
ome
Sel
ecte
d no
tifiab
le
dise
ase
or s
yndr
ome
Any
dis
ease
or h
ealth
eve
nt
Rep
ortin
g U
nit
Hea
lth fa
cilit
ies
Any
one
incl
udin
g he
alth
faci
litie
s
Rep
ortin
g fre
quen
cyIm
med
iate
ly
and
wee
kly
Imm
edia
tely
Rep
ortin
g fo
rmat
Sta
ndar
d N
one
for
othe
r st
akeh
olde
rs
but
stan
dard
for
mat
sho
uld
be u
sed
by
heal
thca
re p
rofe
ssio
nals
)
Rep
ortin
g m
etho
dsE
lect
roni
c W
eb
base
d an
d m
obile
S
MS
text
Ele
ctro
nic
Web
-bas
ed,
mob
ile S
MS
an
d ho
tline
pho
ne
National Early Warning, Alert & Response Surveillance
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1. Roles and Responsibilities
All healthcare professionals working in different level of health facilities are responsible for implementing NEWARS activities. Therefore, it is important that every healthcare professional understand his/her roles and responsibilities as defined in this guideline. Healthcare professionals include specialists, medical doctors, clinical officers, health assistants, nurses, laboratory staffs or others working in various health facilities.
5.1 Clinicians Clinicians including specialists working in the health facilities are the first contact of cases and main source of information NEWARS. Clinicians should: 1 Identify cases of notifiable diseases or
syndromes based on case definition and collect information of cases on daily basis during OPD/IPD/Emergency/MCH/outreach clinic and record in registry or data collection format for weekly notifiable diseases (Annexure 1) and for immediately notifiable diseases (Annexure 2).
2 If data collection form is used, the form should be filed in the file name assigned by health facilities or handover the form to designated NEWARS focal points in the health centers on daily basis.
3 Detect and report immediately notifiable disease base on case definition or if clinicians suspect through NEWARS web based or mobile SMS within 24 hours of detection. Fill in the case investigation form for immediately notifiable diseases or syndromes detected, Use general case investigation form for those diseases
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National Early Warning, Alert & Response Surveillance
that do not have specific investigation form (Annexure 3) Use specific form for Measles. (Annexure 4) Congenital Rubella Syndrome CRS, (Annexure 5) Diphtheria and Pertussis, (Annexure 6) Neonatal Tetanus (Annexure 7) Acute Flaccid Paralysis Surveillance (AFP,) (Annexure 8) and Acute Encephalitis Syndromme (AES) (Annexure 9) should be used for specific disease provided by respective programme).
5.2 Surveillance Focal Points (SFP):
To implement NEWARS effectively, two competent persons in each BHU, BHU-1, district hospitals, and referral hospitals should be designated as the Surveillance Focal Points (SFP). One of the SFPs should be designated as primary focal point and should be responsible for collection, collation and reporting data generated from the health facilities in NEWARS information system. In absence of the primary SFP, the second designated SFP should take up the responsibility. SFP should:
1. Compile NEWARS data collected by clinicians and relevant health professionals at the end of the day on daily basis or whatever mechanism put in place by respective health facilities management,
2. Collate the surveillance data of notifiable diseases or syndromes against specified age group and gender for the specific epidemiological
National Early Warning, Alert & Response Surveillance
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week.
3. Refer case of immediately notifiable disease/syndrome to the nearest health facilities with laboratory facility (for BHU’s) for sample collection,
4. Report collated data on weekly basis through web based or mobile SMS on Monday and Tuesday for previous week and file forms at health centre.
5. Submit zero report if there is no case detected during the epidemiological week on Monday and Tuesday for previous week and file forms at health centre.
5.3 District Health Offices
District Health Offices should play important role in monitoring NEWARS reporting status of health centers under its jurisdiction. DHO or designated staff in DHO office should:
1. Monitor timeliness of NEWARS data reporting of their health centers.
2. Follow-up with late reporting or non-reporting healthcare centers.
3. Sensitize and conduct training of new recruits of health centers
4. Follow-up with the health centers whenever an immediately notifiable disease or syndrome
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National Early Warning, Alert & Response Surveillance
is reported and activate District Health Rapid Response Team (DHRRT) to investigate immediately notifiable disease or syndrome reported if required.
5. Follow-up and monitor when events are reported and activate DHRRT to investigate the event, if required.
6. Ensure the investigation of outbreak initiated within 48 hours of receiving the verification and recommendation.
7. Analyze and interpret NEWARS data submitted by its health centers, prepare and disseminate feedback to health centers periodically,
8. Liaise and communicate with RCDC to sort out any issues related to NEWARS and seek assistance.
5.4 Laboratories in BHU I, district and referral hospitals:
Sample collection and testing by laboratory is critical in confirming etiology of notifiable disease reported including outbreak. Staff in a laboratory should:
1. Collect suitable specimen as per the Standard Operating Procedure (SOP).
2. Analyze samples and provide reports to the health centers,
3. Aliquot and store specimens at appropriate
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temperature in refrigerator or freezer and ship to RCDC in proper cold chain if required.
4. Liaise and communicate with reference laboratories at RCDC if required for any advice or assistance related to laboratory sample collection, shipment, diagnosis of notifiable diseases and events.
5.5 National Disease Surveillance and Epidemiology Unit, RCDC
National Disease Surveillance and Epidemiology (NADSAE) is the focal point for NEWARS. National surveillance focal at NADSAE should:
1. Follow up health centers to ensure timely and accurate reporting.
2. Routinely validate data reported by health centers.
3. Verify immediately notifiable diseass or syndromes reported by health centers.
4. Verify events reported and perform risk assessment.
5. Provide appropriate recommendation for immediately notifiable disease and syndrome reported and verify events within six hours and not later than 24 hours upon notification by health centers in NEWARS.
6. Coordinate response support for immediately notifiable disease and syndrome and events verified with health centers, district health rapid response team.
7. Lead national rapid response team to
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National Early Warning, Alert & Response Surveillance
response outbreak/epidemic and pandemic of national and international public health concern.
8. Analyze surveillance data collected in NEWARS.
9. Prepare and disseminate monthly disease epidemiology report and quarterly disease surveillance bulletin to all health centers and relevant stakeholders.
10. Conduct training for health professionals on NEWARS.
Conduct periodic evaluation of NEWARS and update guideline and system.5.6 Reference Laboratories in RCDC
Reference laboratories play critical role in confirming etiology of notifiable disease and outbreaks. Reference laboratories should:
1. Provide confirmatory diagnosis for notifiable diseases and events.
2. Provide technical assistance to peripheral laboratories in sample collection, storage, shipment and diagnosis of diseases and events.
3. Support diagnostic supplies for all the district laboratories for diagnosis of notifiable and important public health diseases.
4. Provide prompt result for samples referred by health centers.
National Early Warning, Alert & Response Surveillance
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5. Refer samples to supranational reference laboratories as and when required.
5.7 Information Technology (IT) Unit, RCDC
Information technology is the backbone for developing, updating and maintaining NEWARS information system. IT unit should:
1. Maintain and update web-based reporting system and data management applications.
2. Upgrade IT system as and when required.
3. Support health centers related to system problems.
4. Assist NADSAE in preparing monthly report and quarterly disease surveillance bulletin.
5. Supports NADSAE in training health professionals in NEWARS
5.8 National IHR Focal Point, Emergency Medical Service DivisionAs per the IHR 2005 guideline, any disease or events of international concern should be reported to WHO through National IHR focal Point that may constitute a Public Health Emergency of International Concern (PHEIC). National IHR Focal Point should:
1. Assess an outbreak or event reported and see if the event report falls under the
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National Early Warning, Alert & Response Surveillance
purview of PHEIC using the “IHR (2005) Decision Instrument”.
2. Report to Health Emergency Operation Committee
3. Notify WHO country office if the event constitutes a PHEIC and help implement response measures.
4. Provide all relevant public health information to WHO if there is evidence of an unexpected or unusual public health event in the country.
5. Respond to WHO’s request for verification of reports from sources other than notifications or consultations of events.
5.9 Department of Public Health Related divisions under Department of Public
Health (DoPH), particularly Communicable Disease Division are the main stakeholder in NEWARS. Concerned programme under the Department should:
1. Define programme surveillance needs in NEWARS if require,
2. Support funding and training activities of health personnel at various health levels on NEWARS.
3. Mobilization resources to maintain and improve the quality of surveillance.
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National Early Warning, Alert & Response Surveillance
Notifiable Disease Surveillance
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Notifiable Disease Surveillance
1. What is a Notifiable Disease Surveillance System?
National notifiable disease surveillance system is nation-wide indicator-based disease surveillance (IBS). The surveillance collects information for list of diseases or syndromes selected by the Ministry of Health and report timely by healthcare professionals as per the defined timeframe.
2. Criteria for selection of list of disease or syndrome
● Which have epidemic potential.● Which are vaccine preventable.● Which are aimed for elimination.● Which high morbidity and mortality.● Which are of potential threat to international
community (Public Health Emergencies of International Concerns).
3. Data Sources for notifiable disease surveillance Data form or registries of Out-patient, In-patient, Mother Child Health, Outreach and Emergency, outreach clinics of all health facilities.
4. List of national notifiable diseases or syndromes and case definitionsThe list of weekly and immediately notifiable diseases and syndromes and their case definition for surveillance purpose in given in the table-2 and 3 respectively:
Page 29 of 144
National Early Warning, Alert & Response Surveillance
Tabl
e 2:
Lis
t of
wee
kly
notifi
able
dis
ease
s or
syn
drom
es a
nd i
ts c
ase
defin
ition
SND
isea
ses
or
synd
rom
esC
ode
Cas
e D
efini
tion
IA
cute
Blo
ody
Dia
rrhe
a 02
Any
per
son
with
acu
te d
iarr
hea
with
vis
ible
blo
od /
or
muc
us in
the
stoo
l
IIA
cute
Wat
ery
Dia
rrhe
a 03
Any
per
son
with
acu
te w
ater
y di
arrh
ea (p
assa
ge o
f 3 o
r m
ore
loos
e or
wat
ery
stoo
ls in
the
past
24
hour
s) w
ith
or w
ithou
t deh
ydra
tion
IIIA
cute
Ja
undi
ce
Syn
drom
e 07
Any
per
son
with
acu
te o
nset
of j
aund
ice
AN
D a
bsen
ce
of a
ny k
now
n pr
edis
posi
ng fa
ctor
s
OR
Acu
te il
lnes
s ty
pica
lly in
clud
e ac
ute
jaun
dice
dar
k ur
ine,
abr
upt o
nset
of f
ever
, mal
asie
, ano
rexi
a, n
ause
a,
and
vom
iting
IVA
cute
R
espi
rato
ry
Infe
ctio
n 08
Any
per
son
with
his
tory
of f
ever
or
mea
sure
d fe
ver
of
≥ 38
°C A
ND
cou
gh o
r sor
e th
roat
AN
D o
nset
with
in th
e la
st 7
day
s
National Early Warning, Alert & Response Surveillance
Page 30 of 144
VD
engu
e fe
ver
10
Any
per
son
with
acu
te fe
brile
illne
ss o
f 2-7
day
s du
ratio
n w
ith t
wo
or m
ore
of t
he f
ollo
win
g: H
eada
che,
Ret
ro-
orbi
tal
pain
Mya
lgia
/ A
rthra
lgia
/ R
ash/
Hae
mor
rhag
ic
man
ifest
atio
ns/T
ourn
ique
t tes
t pos
itive
.(H
isto
ry o
f tra
vel/l
ivin
g to
the
ende
mic
are
a)
VI
Mum
ps
11
Any
per
son
with
acu
te o
nset
of
unila
tera
l or
bila
tera
l te
nder
, sel
f-lim
ited
swel
ling
of th
e pa
rotid
pre
-aur
icul
ar,
sub-
man
dibu
lar
or o
ther
sal
ivar
y gl
and,
last
ing
2 da
ys
or m
ore,
and
with
out o
ther
app
aren
t cau
se.
VII
Feve
r w
ith
Ras
h 13
Any
per
son
pres
entin
g w
ith fe
ver
and
mac
ula-
papu
lar
rash
(non
-ves
icul
ar)
VIII
Fo
od
-bo
rne
Illne
ss14
Any
per
son
expe
rienc
e ga
stro
inte
stin
al ill
ness
(vom
iting
or
abd
omin
al c
ram
ps o
r di
arrh
ea)
afte
r in
gest
ion
of
food
s or
drin
ks s
uspe
cted
to
be c
onta
min
ated
with
ba
cter
ia, c
hem
ical
sub
stan
ces
and
or to
xins
.
Page 31 of 144
National Early Warning, Alert & Response Surveillance
IXT
yp
ho
id/
Par
atyp
hoid
/E
nter
ic fe
ver
21A
n ill
ness
with
pro
long
ed fe
ver (
>3 d
ays)
, con
stitu
tiona
l sy
mpt
oms
(e.g
. m
alai
se,
head
ache
, an
orex
ia)
AN
D
hepa
to-s
plen
omeg
aly
XS
ever
e A
cute
R
esp
ira
tory
In
fect
ion
23A
ny p
erso
n w
ith a
cute
resp
irato
ry in
fect
ion
with
: His
tory
of
feve
r or F
ever
≥ 3
8 ºC
AN
D C
ough
AN
D o
nset
with
in
the
last
10
days
AN
D re
quire
s ho
spita
lizat
ion.
XI
Ric
ketts
iose
s24
Any
pat
ient
with
an
acut
e un
diffe
rent
iate
d fe
brile
illn
ess
of ≥
5 d
ays
with
at-l
east
one
or
mor
e of
the
follo
win
g si
gns
and
sym
ptom
s: e
scha
r, he
adac
he, r
ash,
cou
gh,
gene
ral m
alai
se, m
yalg
ia, l
ymph
aden
opat
hy.
National Early Warning, Alert & Response Surveillance
Page 32 of 144
Tabl
e 3:
Lis
t of i
mm
edia
tely
not
ifiab
le d
isea
ses
or s
yndr
omes
and
cas
e de
finiti
ons
Sl.
no.
Dis
ease
s/S
yndr
ome
SM
S
Cod
eC
ase
Defi
nitio
n
1A
nthr
ax10
0
Any
per
son
with
acu
te o
nset
of a
ny o
f the
follo
win
g cl
inic
al fo
rms:
and
has
an
epid
emio
logi
cal l
ink
to c
onfir
med
or s
uspe
cted
ani
mal
cas
es o
r co
ntam
inat
ed a
nim
al p
rodu
cts.
Cut
aneo
us: s
kin
lesi
on e
volv
ing
over
1 to
6 d
ays
from
a p
apul
ar th
roug
h a
vesi
cula
r sta
ge, t
o a
depr
esse
d bl
ack
esch
ar in
varia
bly
acco
mpa
nied
by
oede
ma
that
may
be
mild
to e
xten
sive
.G
astr
oint
estin
al: a
bdom
inal
dis
tress
cha
ract
eriz
ed
by n
ause
a, v
omiti
ng, a
nore
xia
and
follo
wed
by
feve
r. Pu
lmon
ary
(inha
latio
n): b
rief p
rodr
ome
rese
mbl
ing
acut
e vi
ral r
espi
rato
ry il
lnes
s, fo
llow
ed b
y ra
pid
onse
t of
hyp
oxia
, dys
pnoe
a an
d hi
gh te
mpe
ratu
re, w
ith
X-r
ay e
vide
nce
of m
edia
stin
al w
iden
ing
Page 33 of 144
National Early Warning, Alert & Response Surveillance
2A
cute
Fla
ccid
P
aral
ysis
101
Any
chi
ld u
nder
fifte
en y
ears
of a
ge w
ith a
cute
flac
cid
para
lysi
s (A
FP)
whi
ch is
defi
ned
by s
udde
n on
set
of p
aral
ysis
occ
urrin
g in
all
parts
of t
he b
ody
and
is
char
acte
rized
by
: Dro
opin
g of
the
affe
cted
join
t (s)
, D
ecre
ase
or a
bsen
ce o
f res
ista
nce
of th
e af
fect
ed
mus
cles
whe
n pu
shin
g (R
efer
VD
CP
surv
eilla
nce
guid
elin
e).
OR
Acu
te F
lacc
id P
aral
ysis
is th
e su
dden
ons
et o
f w
eakn
ess
and
flopp
ines
s in
any
par
t of t
he b
ody
in
a ch
ild <
15
year
s of
age
or p
aral
ysis
in a
per
son
of
any
age
in w
hom
pol
io is
sus
pect
ed”
3A
cute
H
aem
orrh
agic
Fe
ver
Syn
drom
e 1
02
Any
per
son
with
acu
te o
nset
of f
ever
with
any
two
of th
e fo
llow
ing:
hae
mor
rhag
ic o
r pur
puric
rash
, ep
ista
xis
haem
atem
esis
, hae
mop
tysi
s, b
lood
in
sto
ols,
oth
er h
aem
orrh
agic
sym
ptom
and
no
know
n pr
edis
posi
ng h
ost f
acto
rs fo
r hae
mor
rhag
ic
man
ifest
atio
ns.
National Early Warning, Alert & Response Surveillance
Page 34 of 144
4Av
ain
Influ
enza
103
A pe
rson
hos
pita
lized
with
with
acu
te o
nset
of f
ever
of
>38
°C a
nd c
ough
or s
ore
thro
at in
the
abse
nce
of o
ther
dia
gnos
es (A
RI)
and
had
expo
sure
to s
ick/
dead
bird
s O
R li
ving
in a
vill
age
with
co
nfirm
ed a
vian
influ
enza
in b
irds.
5B
acte
rial
Men
ingi
tis10
4
A pe
rson
pre
sent
ing
with
acu
te o
nset
of f
ever
(> 3
8.0
°C) A
ND
hea
dach
e A
ND
at l
east
one
of t
he fo
llow
ing
sign
s: n
eck
stiff
ness
, pro
ject
ile v
omiti
ng, a
ltere
d co
nsci
ousn
ess
(leth
argy
, del
irium
, and
com
a).In
ch
ildre
n le
ss th
an y
ear,
susp
ect m
enin
gitis
whe
n fe
ver a
ccom
pani
ed b
y bu
lgin
g fo
ntan
elle
.
6C
hole
ra10
5In
an
area
whe
re th
e di
seas
e is
not
end
emic
, sev
ere
dehy
drat
ion
or d
eath
from
acu
te w
ater
y di
arrh
oea
in
a pa
tient
age
d 5
year
s or
mor
e
Page 35 of 144
National Early Warning, Alert & Response Surveillance
7M
alar
ia10
6
Any
per
son
with
feve
r, ch
ills,
mya
lgia
s an
d ar
thra
lgia
s, h
eada
che
diar
rhea
, vom
iting
, and
non
-sp
ecifi
c si
gn a
nd th
e de
tect
ion
of P
lasm
odiu
m
spec
ies
by ra
pid
diag
nost
ic a
ntig
en te
stin
g o
r by
mic
rosc
opy
8M
easl
es/
Rub
ella
107
Any
per
son
pres
entin
g w
ith fe
ver w
ith m
acul
opap
ular
ra
sh (n
on-v
esic
ular
) or a
pat
ient
who
m a
hea
lth-c
are
wor
ker s
uspe
cts
has
mea
sles
or r
ubel
la ir
resp
ectiv
e of
the
age
9P
ertu
ssis
108
Any
per
son
with
a c
ough
last
ing
for a
t lea
st 2
wee
ks
with
at l
east
one
of t
he fo
llow
ing:
Par
oxys
m (i
.e. fi
ts
of c
ough
ing)
, ins
pira
tory
“who
opin
g” p
ost-t
ussi
ve
vom
iting
(i.e
. vom
iting
imm
edia
tely
afte
r cou
ghin
g)
with
out o
ther
app
aren
t cau
se O
R A
pnea
(with
or
with
out c
yano
sis)
in in
fant
s (a
ge <
1-ye
ar o
ld) w
ith
coug
h of
any
dur
atio
n O
R If
a p
hysi
cian
sus
pect
s pe
rtuss
is in
a p
atie
nt w
ith c
ough
of a
ny d
urat
ion
National Early Warning, Alert & Response Surveillance
Page 36 of 144
10C
onge
nita
l R
ubel
la
Syn
drom
e (C
RS
)10
9
An
infa
nt w
ith a
t lea
st tw
o of
the
com
plic
atio
ns
liste
d in
(a) b
elow
or o
ne in
(a) a
nd o
ne in
(b):
(a)
Cat
arac
t(s),
cong
enita
l gla
ucom
a, c
onge
nita
l hea
rt di
seas
e, lo
ss o
f hea
ring,
pig
men
tary
retin
opat
hy.
(b) P
urpu
ra, s
plen
omeg
aly,
mic
roce
phal
y, m
enta
l re
tard
atio
n, m
enin
goce
phal
itis,
radi
oluc
ent b
one
dise
ase,
jaun
dice
that
beg
ins
with
in 2
4 ho
urs
afte
r bi
rth.
11R
abie
s (h
uman
)11
0
Any
per
son
with
an
acut
e ne
urol
ogic
al s
yndr
ome
(enc
epha
litis
) dom
inat
ed b
y fo
rms
of h
yper
activ
ity
(furio
us ra
bies
) or p
aral
ytic
syn
drom
es (d
umb
rabi
es)
that
pro
gres
ses
tow
ards
com
a an
d de
ath,
usu
ally
by
resp
irato
ry fa
ilure
, and
has
an
epid
emio
logi
cal l
ink
to
confi
rmed
or s
uspe
cted
ani
mal
cas
es o
r exp
osur
e to
co
ntam
inat
ed a
nim
al p
rodu
cts.
Page 37 of 144
National Early Warning, Alert & Response Surveillance
12
Sev
ere
Den
gue
or
Den
gue
hem
orrh
agic
fe
ver (
DH
F)
111
A a
ny p
erso
n ch
arac
teriz
ed b
y on
e or
mor
e of
th
e fo
llow
ing;
pos
itive
tour
niqu
et te
st; p
etec
hiae
, ec
chym
oses
, or p
urpu
ra; b
leed
ing
(muc
ous,
GI,
or
othe
r): h
emat
emes
is o
r mel
ena;
thro
mbo
cyto
peni
a;
or e
vide
nce
of p
lasm
a le
akag
e. T
he p
lasm
a le
akag
e is
man
ifest
ed b
y on
e or
mor
e of
the
follo
win
g fe
atur
es: (
Equ
al o
r les
s th
an 2
0% ri
se in
ave
rage
he
mat
ocrit
for a
ge a
nd s
ex; e
qual
or m
ore
than
20%
dr
op in
hem
atoc
rit fo
llow
ing
volu
me
repl
acem
ent
treat
men
t is
the
sign
s of
pla
sma
leak
age.
)
13N
eona
tal
Teta
nus
112
Any
new
born
with
a n
orm
al a
bilit
y to
suc
k an
d cr
y du
ring
the
first
two
days
of l
ife, A
ND
who
can
not s
uck
norm
ally
and
bec
ome
stiff
AN
D/O
R h
as c
onvu
lsio
ns
AN
D/O
R d
ied
betw
een
3 an
d 28
day
s of
age
.
14D
ipht
heria
113
A pe
rson
with
an
illne
ss c
hara
cter
ized
by
lary
ngiti
s O
R p
hary
ngiti
s O
R to
nsill
itis,
AN
D a
n ad
here
nt
mem
bran
e of
the
tons
ils, p
hary
nx o
r nos
e O
R *i
llnes
s in
volv
ing
the
muc
ous
mem
bran
e of
upp
er re
spira
tory
tra
ct w
ith m
arke
d sw
ellin
g of
nec
k (b
ull n
eck)
National Early Warning, Alert & Response Surveillance
Page 38 of 144
15A
cute
E
ncep
halit
is
Syn
drom
e11
4
Acu
te o
nset
of f
ever
AN
D a
cha
nge
in m
enta
l st
atus
(inc
ludi
ng s
ympt
oms
such
as
conf
usio
n,
diso
rient
atio
n, c
oma,
or i
nabi
lity
to ta
lk) O
R n
ew
onse
t of s
eizu
res
(exc
ludi
ng s
impl
e fe
brile
sei
zure
s in
chi
ldre
n). M
ay a
lso
incl
ude:
incr
ease
d irr
itabi
lity,
so
mno
lenc
e or
abn
orm
al b
ehav
ior g
reat
er th
an th
at
seen
with
usu
al fe
brile
illn
ess.
Page 39 of 144
National Early Warning, Alert & Response Surveillance
5. How the notifiable disease surveillance system (NDSS) works?
The national NDSS is divided into two reporting system; weekly and immediately. The weekly reporting system collects information on occurrence of notifiable diseases or syndromes (Table 2) by clinicians/nurses/other healthcare professional every day. Cases are then collated and reported every week by designated surveillance (SFP) focal persons of healthcare centers. The reporting is done either through web-based or mobile SMS to RCDC. When no case is detected, SFP does weekly zero reporting to ensure that a health center has not detected any notifiable disease or syndrome. The Dzongkhag Health Offices (DHOs) monitors’ weekly reporting status and data quality of health center under his/her jurisdiction.
The immediately notifiable disease reporting system collects information on those diseases or syndromes (Table 3) by individual clinicians/nurses/other healthcare professional as and when cases are detected. The reporting is done either through web-based or mobile SMS and submit Case investigation form to NADSAE, RCDC. The surveillance officer of NADSAE unit verifies and provided recommendations for response.
The NADSAE analyzes data obtained from all healthcare centers and provides feedback in report or bulletin to all the reporting centers on monthly, quarterly and yearly basis in hard copy and uploads in RCDC website. The feedback is also
National Early Warning, Alert & Response Surveillance
Page 40 of 144
disseminated to the Ministry of Health and relevant stakeholders.
Figure 1: Flowchart of notifiable disease surveillance
6. How to collect, collate and report weekly notifiable diseases and syndrome data?
6.1 Data Collection: The weekly reporting requires collecting information of ‘cases’ and ‘deaths’ of notifiable diseases and syndromes.
● Identify cases based on case definition and collect information of cases or deaths on daily basis from Out-patient/In-patient/Emergency/MCH/ Outreach clinics in weekly reporting form or suitable form developed by respective health centers or from registry.
● If OP/IP/Emergency/outreach clinic registry is used for data collection, make sure that an appropriate coding or identification mark
Page 41 of 144
National Early Warning, Alert & Response Surveillance
is used in the registry for easy data collation by surveillance focal point.
● If data collection form is used, file it in the file assigned or handover to surveillance focal point.
6.2 Data Collation: All ‘cases’ and ‘deaths’ of notifiable diseases and syndromes identified for the week should be collated.
● From “Weekly Reporting Form” (Annex 1) or other suitable form developed, collate data about cases or deaths identified during the epidemiological week calendar (that is the reporting period for every Epi Week should be from Monday to Sunday).
● All cases and deaths should be collated as per the age group and gender specified for each notifiable diseases or syndromes.
● For In-patient cases or deaths, review both the ‘admission diagnosis’ and ‘symptoms’ in the register to see if the cases or death meets the case definition.
● Mark (e.g. tick) those cases in the register that are included in the “Weekly Reporting Form” so that it can be validated if needed during evaluation and monitoring process.
● Mark (e.g. draw a line under) the last case in the register included in the weekly report. This will help the data collation for the subsequent week.
● Double check and validate data before reporting.
National Early Warning, Alert & Response Surveillance
Page 42 of 144
6.3 Data reporting: All ‘cases’ and ‘deaths’ of notifiable diseases and syndromes identified and collated for the week should be reported.
● Either through web-based in RCDC website or mobile SMS every Monday and Tuesday for the previous epidemiological week. Healthcare centers reporting on Monday or Tuesday will be recorded as timely reporting.
● If no case or death of notifiable diseases or syndromes are detected for the week, zero-reporting should be done. Zero-reporting is an evidence of no case or death for the week.
6.4 Data Verification: Verification is important to improve and maintain data quality.
● Upon the submission of data from all healthcare centers, the designated surveillance officer at NADSAE, RCDC will verify all the data received in the system.
● If any discrepancy is observed in the reported data, the surveillance officer will call or email to the SFP of that particular healthcare center to verify once again by going through the data stored in hard copy and ask them to verify once again and make necessary changes if required.
7. How to report immediately notifiable diseases or syndrome?The list of immediately notifiable diseases or syndromes are public health important and even a single case requires reporting for follow up action.
Page 43 of 144
National Early Warning, Alert & Response Surveillance
7.1 Reporting: ● All healthcare professionals should report
any case or death of the immediately reportable disease or syndromes either through web-based or mobile SMS as soon as possible or within 12 hours of detection.
● Upon verification, the concerned health professional should fill up case investigation form (CIF) developed for specific disease or syndrome and submit the scan copy of CIF in the NEWARS system.
● Suitable sample should also be collected from case and send to RCDC for analysis.
● When no case is detected, SFP should submit weekly zero reporting to ensure that a health center has not detected any immediately notifiable disease or syndrome for that week.
7.2 Verification: ● Upon the submission of report by the
concerned healthcare professional, the designated surveillance officer at NADSAE, RCDC will verify the report.
● If any discrepancy is suspected, the surveillance officer will call and verify.
● The surveillance officer will verify CIF submitted and contact reported person if any there is any discrepancy or incomplete information.
7.3 Response: The concerned healthcare professional in
consultation with district health authority or hospitals management should initiate
National Early Warning, Alert & Response Surveillance
Page 44 of 144
Figure 2: Flow chart for immediately reporting and response
the investigation of immediately reported diseases within six working hours after receiving the recommendations from
Page 45 of 144
National Early Warning, Alert & Response Surveillance
EVENT-BASED SURVEILLANCE
National Early Warning, Alert & Response Surveillance
Page 46 of 144
EVENT-BASED SURVEILLANCE
1. What is an Event-based Surveillance?An event-based surveillance (EBS) is rapid gathering of information about any health event that poses potential risk to public health. EBS involves gathering of health information from various sources, conducting verification and performing risk assessment and providing appropriate recommendation /responses based on the outcome of verification and risk assessment. This information can be rumors, or any adhoc reports that are transmitted through formal channel by health professionals and community health workers and informal channels such as mainstream and social media, community leaders (Local Government), and non-governmental organizations related to;• Occurrence of disease or syndrome occurrence
in cluster in human,• Unusual pattern of disease or syndrome, • Unusual cluster of deaths,• Diseases and deaths in animals,• Contaminated food and food products, and
environmental hazards including chemical and radio-nuclear.
Unlike IBS, EBS is not based on the routine collection of data and automated thresholds for action but rather on unstructured descriptions and reports. However, EBS can complements IBS as IBS often fail to timely detect events of public health concern such as outbreak.
Page 47 of 144
National Early Warning, Alert & Response Surveillance
2. What are the events of public health concernAn event is considered public health concerns if:• Underlying agent, disease or mode of
transmission is new, newly discovered or unknown at the time of notification;
• Potential transmission through vectors, cargo or goods (including food products) and environmental dispersion;
• Unusual occurrence pattern for specific disease or syndrome, single or in cluster.
• Event related to exposure to biological (of infectious or non-infectious in nature), chemical agents or radio nuclear materials.
3. Sources of events Information Event-based surveillance (EBS) requires a multi-sectorial approach and relies on sources of information beyond conventional health system sources (e.g. indicator-based surveillance). Events are most likely to be detected in the community, institutes (schools, monasteries), army barrack, public functions (religious rites, festivals) and healthcare centers. Media is one of the important reporting sources and any event reported in TV, radio and print including news internet should be considered as an event reported.
National Early Warning, Alert & Response Surveillance
Page 48 of 144
Tabl
e 4:
Sou
rce
of e
vent
repo
rt
Med
ical
Set
ting
Hea
lthca
re
faci
litie
s H
ospi
tals
, BH
Us
and
Sub
-pos
tH
ealth
Hel
p C
ente
r A
irpor
t Hea
lth S
ervi
ce U
nit,
and
grou
nd b
orde
r cro
ssin
g po
ints
Non
-hea
lth
orga
niza
tions
Vete
rinar
y se
rvic
es
Bhu
tan
Agr
icul
ture
and
Foo
d R
egul
ator
y A
utho
rity
Wild
life
Env
ironm
enta
l Hea
lth (N
EC
) P
harm
acy
Sal
e co
unte
rC
omm
unity
set
tings
Com
mun
ity
Villa
ge h
ealth
wor
kers
Vi
llage
ani
mal
hea
lth w
orke
rs
Mul
ti-S
take
hold
er T
ask
Forc
e (M
STF
) of
dis
trict
sC
omm
unity
lead
ers
Gen
eral
pub
lic
Page 49 of 144
National Early Warning, Alert & Response Surveillance
Med
iaM
edia
(pr
int,
radi
o, T
V, in
tern
et)
Inst
itute
s an
d
orga
niza
tion
Non
Gov
ernm
enta
l Org
aniz
atio
ns
Mili
tary
(Arm
y &
Pol
ice)
In
tern
atio
nal o
rgan
izat
ions
R
elig
ious
org
aniz
atio
ns, I
nstit
utes
, U
nive
rsiti
es,
and
Mun
icip
ality
4. E
vent
info
rmat
ion
colle
ctio
n A
ny e
vent
s to
be
repo
rted,
the
follo
win
g fir
st h
and
info
rmat
ion
shou
ld b
e co
llect
ed
1.
Wha
t do
you
wan
t to
repo
rt (N
ame
of s
uspe
ct e
vent
/out
brea
k)2.
W
hen
did
this
hap
pene
d (D
ate/
Tim
e of
eve
nt/o
utbr
eak)
?3.
W
here
this
did
hap
pene
d (lo
catio
n of
eve
nt/o
utbr
eak)
?4.
H
ow m
any
peop
le a
ffect
ed w
hen
you
dete
cted
(num
ber o
f cas
es)?
5.
List
com
mon
sig
ns a
nd s
ympt
oms?
6.
Add
ition
al in
form
atio
n us
eful
for v
erifi
catio
n an
d in
vest
igat
ion.
National Early Warning, Alert & Response Surveillance
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5. Event Reporting
Any disease(s), death(s) or events that are considered as unusual by health professionals should be immediately reported as an event to NEWARS system not limited to the list defined in Table 5.
Event collected using (Annexure 10) should be reported immediately or within 24 working hours of detection at the health facility by the concerned health professional. Events can be reported by village health workers, schools and institutes, community group leaders, people working in NGO’s/CSO’s and general public including media persons through RCDC website. However, this may need sensitization of those stakeholders through various forums.
Those events which are considered Public Health Emergency of International Concerns (PHEIC) should be reported to WHO through IHR National Focal Point (NFP) in according to the decision chart (Annexure 4).
The events which have serious public health implication should be also reported to National Disaster Management Authority by Emergency Medical Service Division, Department of Medical Services as per Disaster Management Act of Bhutan 2013.
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National Early Warning, Alert & Response Surveillance
Tabl
e 5:
Rep
orta
ble
Eve
nts
SNEv
ents
Defi
nitio
n1
Out
brea
ks o
f any
di
seas
eA
grou
p pe
ople
are
sic
k w
ith s
imila
r sym
ptom
s in
one
pla
ce
(e.g
. vill
age,
sch
ool,
heal
th fa
cilit
y, e
tc.)
at th
e sa
me
time.
2C
lust
er o
f unu
sual
de
ath(
s)
Two
or m
ore
peop
le d
ie o
f unk
now
n ca
use
afte
r suf
ferin
g fro
m s
imila
r sym
ptom
s in
one
pla
ce (e
.g. v
illag
e, s
choo
l, or
he
alth
faci
lity)
at t
he s
ame
time.
3Fo
od b
orne
illn
ess
A gr
oup
of p
eopl
e be
com
e si
ck o
r hav
e an
othe
r unu
sual
re
actio
n af
ter c
onsu
min
g th
e sa
me
food
or d
rinks
from
the
sam
e w
ater
sou
rce.
4E
xpos
ure
to
chem
ical
sA
grou
p of
peo
ple
beco
me
sick
or h
ave
anot
her u
nusu
al
reac
tion
afte
r bei
ng e
xpos
ed to
any
che
mic
al a
gent
.5
Em
ergi
ng
infe
ctio
us d
isea
seA
ny p
erso
n w
ith s
ympt
oms
you
have
not
see
n be
fore
or n
ot
seen
for a
long
tim
e in
a p
lace
.6
Zoon
otic
dis
ease
Peo
ple
and
anim
al b
ecom
e si
ck o
r die
at t
he s
ame
time
in a
lo
calit
y.
National Early Warning, Alert & Response Surveillance
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6. Event Verification
Verification of events reported is important to validate information. Information validation absolutely necessary when the event is reported by other allied stakeholders or public.
NADSAE will verify the event by following-up with the reporting health center or other sources. Verification and validation of the reported event should be done immediately or within 6 hours after notification.
7. Event Risk Assessment
Risk assessment is important to understand the scale and magnitude of the event. All events reported following verification will be subjected to risk assessment by NADSAE to determine potential risk to public health and make necessary recommendation. The risk assessment will be done using following assessment questionnaires in the Table 6.
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National Early Warning, Alert & Response Surveillance
Tabl
e 6:
Crit
eria
for a
sses
smen
t of p
ublic
hea
lth ri
sk o
n fir
st re
porti
ng o
f an
even
t
SNQ
uest
ions
Yes
No
1Is
the
even
t rep
orte
d fro
m c
ongr
egat
ed o
r ins
titut
iona
l set
ting
(eg,
sc
hool
, dra
tsha
ng)?
2C
an th
e re
porte
d ev
ent c
ause
out
brea
ks w
ith h
igh
pote
ntia
l for
sp
read
?3
Is th
ere
a hi
gher
than
exp
ecte
d m
orbi
dity
from
the
dise
ase?
4Is
ther
e an
y m
orta
lity
repo
rted
from
this
eve
nt?
5Is
ther
e a
clus
ter o
f cas
es w
ith s
imila
r sym
ptom
s?
6C
ould
the
dise
ase
be c
ause
d by
a c
onta
min
ated
food
or w
ater
?
7D
oes
the
dise
ase
have
pos
sibl
e co
nseq
uenc
es f
rom
tra
de o
r tra
vel?
8A
re th
ere
any
asso
ciat
ed o
r pre
cedi
ng e
vent
s (i.
e. a
ttend
ing
pic-
nic,
spo
rts, f
estiv
al, f
uner
al, g
athe
ring,
etc
)?
National Early Warning, Alert & Response Surveillance
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8. Event Response
Response to an event is an essential part of event-based surveillance. Once an event is verified as a potential risk to public health; the response should be initiated immediately by the concerned health center or by the DHRRT based on the level of risk assessed by NADSAE. The response must be initiated in the field within six working hours of risk assessment and recommendation. The investigating team (DHRRT) will submit the preliminary investigation report to NADSAE within 48 hours (Annexure 11) and update daily outbreak situation (Annexure 12). The detail response should be referred “Outbreak investigation and Response manual”. The information flow and the coordination mechanism during the public health events /outbreak should be carried out as per the existing SoP.
9. Reporting of Public Health Events of International Concern
The International Health Regulations (2005) requires notification of event that is public health event of international concerned. Any events of PHIC should be reported to National IHR Focal Point under EMSD by NADSAE for onward reporting to WHO.
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National Early Warning, Alert & Response Surveillance
Figure 3: Flowchart for event reporting and response
National Early Warning, Alert & Response Surveillance
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National Early Warning, Alert & Response Surveillance
Data Analysis, Feedback, Monitoring & Evaluation
National Early Warning, Alert & Response Surveillance
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Data AnalysisTo understand specific patterns of notifiable diseas-es or syndromes occurrence and take necessary interventions, the data analysis and interpretation is important and should be done regularly at all lev-els. The health center should analyze their data, the District Health Office should analyze data obtained from all the health centers under its jurisdiction and the NADSE at national level.
1. Indicator-based Surveillance data analysisSurveillance data can be used to describe health problems in terms of time (week, month, year), place (village, gewog, district,) and person (age, sex). The data can also be used for assessment of following epidemiological parameters:
1. Long-term trend analysis: review your data for the following characteristics: Normal Dis-tribution, Abrupt changes, Cycles, Outliers
2. Seasonal patterns: to understand 3. Analyzing data by place: Analyzing data
according to place gives information about where a disease is occurring. Establishing and regularly updating a spot map of cas-es for selected disease can give ideas as to where, how and the disease is spreading.
A single case of immediately notifiable disease should be described using following parameters:
● Demographic and clinical characteristics of the case
● Place of occurrence● Identify risk factors● Behavioral patterns of the case● contact Tracing
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National Early Warning, Alert & Response Surveillance
Cluster of suspected cases should be investigated and analyzed for:
● Time and place of occurrence (epidemic curve)
● Demographic and clinical characteristics of the cases
● Identification of risk factors● Identification of the source and mode of
transmission of the disease● Geographical distribution of the cases● Identify the magnitude and association of
risk factors with the disease ● Visual demonstration of data with appropri-
ate graphs
2. FeedbackRegular feedback to all health centers and stake-holders is crucial to keep them motivated and im-prove the surveillance. The feedback is also es-sential to reinforce health staff’s effort to actively participate in the surveillance.
● Informal feedback by phone and email should also be used regularly and especially during outbreaks and Public Health Events at all level.
● At district level, DHO should provide ap-propriate feedback and share with respec-tive BHUs and hospitals. This will reinforce health professional efforts to raise aware-ness and improve their participation in the surveillance.
● At national level, NADSE, RCDC should pro-vide feedback through monthly and quarter-ly newsletter and bulletins and disseminate to all health centers and stakeholders. The
National Early Warning, Alert & Response Surveillance
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monthly feedback can be summary of cases report and descriptive analysis for quarterly bulletin describing disease trend and situa-tion.
● In addition feedback through supervisory visit should be shared health centers and monitor implementation of follow-up actions.
Monitoring & EvaluationMonitoring and evaluation is an important compo-nent of any surveillance. In order to scale up re-sponse, all the stakeholders need to constantly re-view their performance in detecting, reporting and responding to diseases and events. The key activi-ties of healthcare professionals for the surveillance system at each administrative level are described under roles and responsibilities section.
Surveillance performance should be monitored & evaluated at each administrative level with aim to improve and sustain existing surveillance system. The DHO and NADSAE should monitor surveil-lance system at least once in a month with set of indicators as described below.
1. Indicators for Monitoring
1.1. Timeliness reporting.
The timeliness reporting should be monitored based on reporting schedule set for health centers of each administrative level. For an indicator-based surveillance, if BHUs and hospitals send report to NADSAE by Monday or Tuesday of subsequent week, it will be considered as timely reporting for
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National Early Warning, Alert & Response Surveillance
previous week. However, if health centers send report on Tuesday to Friday, it is considered as late report and later than that, it will be considered as not reported but record will be kept for future reference. For immediately notifiable disease and events, reporting within 24 hours of detection is considered timely report.
Timeliness is defined as the total number of reports received on time within the time period compared with the total number of reports expected within the time period (irrespective of the time of receipt in NEWARS surveillance system).
a. Timeliness for Weekly reporting: Calculated total number of reports received on time within the given week divided by total number of reports expected in the same week multiple by 100.
b. Timeliness for Immediately reporting: Calculated by total number of immediately notifiable diseases reported within 24 hours divided by total number of same notifiable diseases detected in the same week multiple by 100.
c. Timeliness Response for immediately reported disease Calculated by total number of immediately notifiable diseases responded within 6 hours after receiving recommendation divided by total number of same notifiable diseases detected in the
National Early Warning, Alert & Response Surveillance
Page 62 of 144
same week multiple by 100.
d. Timeliness Response for events response Calculated by total number of events responded within 6 hours of event verification divided by total number of events detected in the same week multiple by 100. .
2. Completeness reporting
Completeness of reporting refers to total number of reports received in the system compared with number of reports expected in the same time period. Calculated by total number of reports received in a given month divided by total number of reports expected in the same month multiple by 100.
3. Evaluation of NEWARS
Evaluation of NEWARS will be conducted to assess its attributes such as sensitivity, specificity, positive predictive value, completeness, timeliness, usefulness, etc as per WHO and US CDC’s guideline of evaluating surveillance system. The period of evaluation will be need-based and the availability of funding source.
4. Supervisory Visit
Supervisory visit should aim to help the health staff to improve their knowledge and performance and not be a fault-finding exercise. Supervisors and health staff work should together review progress, identify problems, and develop feasible solution.
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National Early Warning, Alert & Response Surveillance
Supervisory visits should be conducted at least once a year to help the Surveillance Focal Point to improve their performance. During the visit, (positive feedback and improvements needed) should be provided to health professional. Gaps identified should be tackled on the spot if possible, or solved at a later stage. On-the-job training should also be provided to improve the quality of activities. Supervisory visit debriefing should be done to hospital management and district health authority. A report should be prepared after the visit and share to hospital management and concern Departments which should be used for future visits to follow up recommended actions.
Laboratory TestingLaboratory testing of specimens collected from sus-pected cases should be undertaken to identify the pathogens. This is an important part of the surveil-lance system to establish and understand disease etiology for clinical management. Some diseases or syndromes such as acute flaccid paralysis, fever and rash (suspected measles and rubella) require every case to be confirmed by laboratory testing. Refer Table 7 for detailed information on specimen collection, storage, transport and laboratory testing.
National Early Warning, Alert & Response Surveillance
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Page 65 of 144
National Early Warning, Alert & Response Surveillance
Laboratory Sample Collection, Storage & Testing
National Early Warning, Alert & Response Surveillance
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Tabl
e 7:
Det
ails
of l
abor
ator
y sa
mpl
es c
olle
ctio
n, s
tora
ge a
nd In
vest
igat
ion
SND
isea
se/
syn -
drom
es
Susp
ecte
d et
iolo
gyR
ecom
men
ded
sam
ples
Stor
age
cond
ition
Ship
men
t Te
mp.
Test
s
1 A
nthr
axBa
cillu
s an
thra
sis
1. S
kin
scra
ping
s an
d flu
ids
from
ve
sicl
es
Skin
scr
apin
gs a
nd fl
u-id
s fro
m le
sion
s; 2
-8
°C.
2-8
°CM
icro
scop
y
Bloo
d cu
l-tu
re
E
IA
PCR
2. B
lood
sam
ple
Bloo
d cu
lture
sho
uld
be in
ocu -
late
d im
med
iate
ly a
nd in
cuba
ted
at 3
7 °C
3. S
tool
/Rec
tal
swab
sSe
rum
sho
uld
be s
eper
ated
and
st
ored
at 2
-8 °C
up
to 1
wee
k or
-2
0 °C
if >
1 w
eek.
Rec
tal s
wab
s/St
ool;
Use
Mod
ified
C
ary
Blai
r Tra
nspo
rt (M
CB)
me -
dia.
Sto
re a
t 2-8
°C u
p to
1 w
eek
or -2
0 °C
if >
1 w
eek.
2Ac
ute
Bloo
dy
Dia
rrhea
an
d Ac
ute
Wat
ery
Dia
rrhea
Nor
oviru
s, A
stro
viru
s, R
otav
irus,
Ade
novi
rus,
H
epat
itis
viru
s, S
apov
irus,
Ent
amoe
ba, S
trong
y -lo
ide,
Mic
rosp
orid
ium
Shig
ella
spp,
Sal
mon
ella
spp
, Cam
pylo
bact
er s
pp,
Yers
inia
spp
, Vib
rio s
pp, C
ampy
loba
cter
spp
, D
iarrh
eage
nic
E.co
li, C
lost
ridiu
m s
pp
1. S
tool
/Rec
tal
swab
sR
ecta
l sw
abs/
Stoo
l; U
se M
odifi
ed
Car
y Bl
air T
rans
port
(MC
B) m
e -di
a. S
tore
at -
20 °C
if >
1 w
eek.
2-8
°C1.
Cul
ture
2.
Mi-
cros
copy
3.
EIA
4. P
CR
2. S
erum
Seru
m s
houl
d be
sep
erat
ed a
nd
stor
ed a
t 2-8
°C u
p to
1 w
eek
or
-20
°C if
>1
wee
k.
2. B
lood
sam
ple
Seru
m s
houl
d be
sep
erat
ed a
nd
stor
ed a
t 2-8
°C u
p to
1 w
eek
or
-20
°C if
>1
wee
k.
Page 67 of 144
National Early Warning, Alert & Response Surveillance
4Ac
ute
Ence
pha -
litis
Syn
-dr
ome
Stre
ptoc
occu
s pn
eum
onia
, Nei
sser
ia m
enin
giti-
des,
Hae
mop
hilu
s in
fluen
za, L
iste
ria m
onoc
yto-
gene
s, G
roup
B S
trept
ococ
ci, B
ruce
lla s
peci
es,
Salm
onel
la s
peci
es, M
.tube
rcul
osis
, Myc
opla
sma
pneu
mon
ia, T
repo
nem
a pa
llidum
, Lep
tosp
ira,
Orie
ntia
tsut
suga
mus
hi, R
icke
ttsia
typh
i, Pl
as-
mod
ium
spp
, Tox
opla
sma
gond
ii, N
aegl
eria
and
Ac
anth
amoe
ba, C
ystic
ercu
scel
lulo
sae,
Jap
anes
e En
ceph
aliti
s, D
engu
e,, C
hiku
ngun
ya, E
nter
ovi -
ruse
s, M
easl
es, M
umps
, Rub
ella
, Nip
ah v
irus,
H
erpe
s si
mpl
ex (H
SV),
Varic
ella
zos
ter (
VZV)
, H
uman
Her
pes
Viru
s-6
(HH
V-6)
, Eps
tein
Bar
r, Ad
enov
irus,
Cyt
omeg
alov
irus,
Cry
ptoc
occu
s ne
ofor
man
s, C
andi
da s
peci
es
1. C
SF (W
here
po
ssib
le)
2.
Blo
od s
ampl
e
Seru
m s
houl
d be
sep
erat
ed.
Stor
e se
rum
and
CSF
at a
t 2-8
°C
up
to 1
wee
k or
-20
°C if
>1
wee
k.
2-8
°C1.
Ser
olog
y
2.
EIA
(CSF
) 3.
Bac
teria
l An
tigen
test
5Ac
ute
Flac
cid
Para
lysi
s
Polio
viru
sSt
ool/
Rec
tal
swab
: 2 s
pec -
imen
s to
be
colle
cted
24
hour
s ap
art
Stoo
l sho
uld
be c
olle
cted
with
in
14 h
ours
follo
win
g on
set o
f par
al-
ysis
. Sto
red
at 2
-8 °C
or
at -
20
°C fo
r pro
long
ed s
tora
ge
2-8
°C1.
PC
R
6Ac
ute
Hae
m-
orrh
agic
Fe
ver
Syn -
drom
e
Crim
ean
Con
go H
emor
rhag
uc fe
ver,
Den
gue
vi-
rus,
Ebo
la-M
arbu
rg v
irus,
Den
gue,
Chi
kung
unya
, Ar
enav
irus,
Han
tavi
rus,
Kya
sanu
r for
est d
isea
se
viru
s, L
assa
Fev
er v
irus,
Lep
tosp
ira, R
icke
ttsia
ty
phi,,
Orie
ntia
tsut
suga
mus
hPla
smod
ium
Bloo
d sa
mpl
eSe
rum
sho
uld
be s
eper
ated
and
st
ored
at 2
-8 °C
up
to 1
wee
k or
-2
0 °C
if >
1 w
eek.
2-8
°C1.
Ser
olog
y
2.Pa
thog
en
dete
ctio
n (P
CR
)
7Ac
ute
Jaun
dice
Sy
n -dr
ome
Hep
atiti
s A,
B, C
, D &
E,
Lept
ospi
ra, S
alm
onel
la
spp,
Bru
cella
spp
, M. t
uber
culo
sis,
E.c
oli ,
HSV
, EM
B, C
MB,
Ent
ero
viru
s, A
deno
viru
s
Bloo
d sa
mpl
eSe
rum
sho
uld
be s
eper
ated
and
st
ored
at 2
-8 °C
up
to 1
wee
k or
-2
0 °C
if >
1 w
eek.
2-8
°C1.
Ser
olog
y
2. P
CR
3. B
acte
rial
cultu
re
8Ac
ute
Re -
spira
tory
In
fect
ion
Aden
o vi
ruse
s, R
hino
viru
s Pn
eum
ococ
cus
stre
ptoc
occu
s pn
eum
onia
e
R
espi
ra-
tory
syn
cytia
l viru
s Pa
ra in
fluen
zae
viru
s in
fluen
za
viru
s Av
ian
influ
enza
viru
s H
aem
ophi
lus
influ
enza
B
Legi
onel
la p
neum
ophi
la
Thro
at/N
asal
sw
abN
asal
/Thr
oat s
wab
s a
t 2-
8 °C
up
to 1
wee
k or
-20
°C if
>1
wee
k.2-
8 °C
PC
R
National Early Warning, Alert & Response Surveillance
Page 68 of 144
9Ba
cter
ial
men
in-
gitis
Nei
sser
ia, S
trept
ococ
cus
grou
p B,
Hae
mop
hi-
lusi
nflue
nzae
, Lis
teria
mon
ocyt
ogen
es1.
CSF
2.
Blo
od
3.
Sto
ol
Bloo
d/C
SF c
ultu
re s
houl
d be
per
form
ed im
med
iate
-ly.
Se
rum
, and
SC
F sh
ould
be
sto
red
at 2
-8 °C
up
to 1
w
eek
or -2
0 °C
if >
1 w
eek.
R
ecta
l sw
abs/
Stoo
l; U
se M
odifi
ed
Car
y Bl
air T
rans
port
(MC
B) m
e -di
a. S
tore
at 2
-8 °C
up
to 1
wee
k or
-20
°C if
>1
wee
k.
2-8
°C1.
Bloo
d/C
SF
cultu
re
2.Se
rolo
gy
3.
Mol
ecul
ar
10D
engu
e fe
ver
Den
gue
viru
s ty
pe 1
,2,3
and
4Bl
ood
(Ser
um)
Seru
m s
houl
d be
sep
erat
ed a
nd
stor
ed a
t 2-8
°C u
p to
1 w
eek
or
-20
°C if
>1
wee
k.
2-8
°C1.
PCR
2.
Ser
olog
y
11D
ipht
he-
riaC
orne
ybac
teriu
m d
ipth
eria
e1.
Blo
od (s
erum
) 2.
Thr
oats
wab
3.
piec
es o
f pse
udo -
mem
bran
e
Seru
m s
houl
d be
sep
erat
ed
and
stor
ed a
t 2-8
°C u
p to
1
wee
k or
-20
°C if
>1
wee
k.
Thro
at s
wab
can
be
colle
cted
an
d pl
aced
in s
ilica
gel a
nd s
tore
at
2-8
°C
2-8
°C1.
Cul
ture
, 2.
Sero
logy
, 3.
Mol
ecul
ar
12Fe
ver
with
R
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ver
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st
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up
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ry a
nd s
tor a
t 2-8
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2-8
°C1.
Ser
olog
y 2.
Mol
ecul
ar
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National Early Warning, Alert & Response Surveillance
13Fo
od
born
e illn
ess
Salm
onel
laSh
igel
laC
ampy
loba
cter
jeju
niYe
rsin
ia e
nter
ocol
itica
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oli
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moe
ba h
isto
lytic
a B
cere
us C
lost
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m s
pp
1. V
omitu
s
2. G
astri
c co
nten
t 3.
Sto
ol
4. B
lood
5. F
ood
sam
ple
If im
med
iate
cul
ture
is n
ot
poss
ible
sto
re s
ampl
es a
t 2-8
°C
. Ser
um, v
omitu
s, g
astri
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nten
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food
sam
ples
sh
ould
be
stor
ed 2
-8 °C
up
to
1 w
eek
or a
t -20
°C if
>1
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k.
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r sto
ol s
ampl
e us
e M
odifi
ed
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air T
rans
port
(MC
B)
med
ia.
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e at
2-8
°C u
p to
1 w
eek
or a
t -20
°C if
>1
wee
k.
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°C1.
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teria
l cu
lture
, 2.
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logy
for
Hep
A, E
14M
alar
iaPl
asm
odiu
m s
pp.
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dM
icro
scop
y (th
ick
& th
in s
mea
r).
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epar
e D
ried
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d Sp
ot a
nd
stor
e at
RT
or 2
-8 °C
; Se
rum
/pl
asm
a sh
ould
be
sepe
rate
d an
d st
ored
at 2
-8 °C
up
to 1
wee
k or
-2
0 °C
if >
1 w
eek.
2-8
°C1.
Mic
ros -
copy
,
2.
Sero
logy
3.
Mol
ecul
ar
15Pe
rtuss
isBo
rdet
ella
per
tusi
s1.
Blo
od
2. N
asop
hary
n -ge
al S
wab
s
Seru
m s
houl
d be
sep
erat
ed a
nd
stor
ed a
t 2-8
°C u
p to
1 w
eek
or
-20
°C if
>1
wee
k.
2-8
°C1.
Ser
olog
y
2. B
acte
rial
cultu
re
16R
abie
s (h
uman
)R
abie
s vi
rus
Ser
olog
ySe
rum
sho
uld
be s
eper
ated
and
st
ored
at 2
-8 °C
up
to 1
wee
k or
-2
0 °C
if >
1 w
eek.
2-8
°C S
erol
ogy
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onge
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l Ru-
bella
Syn
-dr
ome
Rub
ella
viru
s1.
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al/th
roat
sw
abs
3.
Urin
e
Seru
m a
nd s
wab
s sh
ould
be
sepe
rate
d an
d st
ored
at 2
-8 °C
up
to 1
wee
k or
-20
°C if
>1
wee
k.
.
2-8
°C1.
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tect
ion,
2.
Sero
logy
18Te
tanu
sC
lost
ridiu
m te
tani
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rum
sho
uld
be s
eper
ated
and
st
ored
at 2
-8 °C
up
to 1
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k or
-2
0 °C
if >
1 w
eek.
2-8
°CSe
rolo
gy
(EIA
ant
itoxi
n Ig
G )
National Early Warning, Alert & Response Surveillance
Page 70 of 144
19Ty
phoi
d /P
ara -
typh
oid
feve
r
Salm
onel
la s
pp1.
Blo
od
2.
Stoo
l/ R
ecta
l sw
ab
Seru
m s
houl
d be
sep
erat
ed
and
stor
ed a
t 2-8
°C u
p to
1
wee
k or
-20
°C if
>1
wee
k.
For s
tool
/Rec
tal s
wab
s us
e M
odifi
ed C
ary
Blai
r Tra
nspo
rt (M
CB)
med
ia.
Stor
e at
2-8
°C
up to
1 w
eek
or -2
0 °C
if >
1 w
eek.
2-8
°C1.
Ser
olog
y
2. B
acte
rial
cultu
re 3
. M
olec
ular
20Se
vere
Ac
ute
Re -
spira
tory
Ill
ness
Influ
enza
viru
s, A
deno
viru
ses,
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no v
irus,
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eum
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stre
ptoc
occu
s pn
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e
, Res
pira
tory
sync
ytia
l viru
s, P
ara
influ
enza
e vi
rus
influ
enza
viru
s, A
vian
influ
enza
viru
s H
aem
ophi
-lu
s in
fluen
za B
, Le
gion
ella
pne
umop
hila
2. N
asal
/thro
at
swab
sN
asal
/Thr
oat s
wab
s at
2-8
°C
up to
1 w
eek
or -2
0 °C
if >
1 w
eek.
2-8
°C1.
Rap
id
assa
y
2.
Vi
ral d
etec
-tio
n
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National Early Warning, Alert & Response Surveillance
NEWARS Information System
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NEWARS Information System
NEWARS is meant to be the real-time surveillance and design to generate specific alerts for appropriate response and this can be achieved only if information technology (IT) based surveillance system is developed.
NEWARS information system was developed in-house by RCDC in 2014. The system was introduced and rolled out to all health centers in 2015. It is a centralized database that collects data from health centers across the country, either through web-based or mobile SMS technology, based on health centers accessibility to internet and mobile network.
The NEWARS system has three reporting platforms; Weekly, Immediately and Events report. The Figure 8 shows the flow of data in the NEWARS system.
Referral Hospitals
District Hospitals BHU I BHU II Satellite
ClinicOutreach
Clinic Subpost
General Public
District Health Office
Figure 8:NEWARS system data flow(need to change no. of diseases)
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1. Features of NEWAR information system
The system has all the required features to capture the entire process of reporting, alerts, notification and response mechanism.
NEWARSIS
Health Centers
SFP, RCDC
District Health Office
Relevant Programmes, MoH
Res
po
nse
SM
S/Em
ail A
lert
Resp
on
se SMS/Em
ail Alert
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Imm
ediate R
epo
rt
SMS/Em
ail Alert
New Immediate Report SMS/Email AlertR
eco
mm
end
atio
n
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l Ale
rt
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om
men
dat
ion
New
Imm
edia
te R
epo
rtResp
onse by h
ealth
cente
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ngkhag RRT/Centra
l RRT
Immediate
Report
Verification
Response
SMS/Email Alert
Recommendation
SMS/Email Alert
New Immediate
Report SMS/Email
Alert
Response
Figure 9: Alert and response mechanism for immediate reporting
NEWARSIS
Health Centers
SFP, RCDC
District Health Office
Relevant Stakeholders
Res
po
nse
SM
S/Em
ail A
lert
Resp
on
se SMS/Em
ail Alert
New
Imm
ediate R
epo
rt
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ail Alert
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om
men
dat
ion
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l Ale
rtR
isk
Ass
essm
ent
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om
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dat
ion
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nt
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ort
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RT
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and assess
event
Response
SMS/Email Alert
Recommendation
SMS/Email Alert
New Event Report
SMS/Email Alert
Communities, Institutes and Allied Centers
Response
Figure 10: Alert and response mechanism for event report
National Early Warning, Alert & Response Surveillance
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1. Practical guide to using NEWARS in-formation system (NEWARSIS)
Open a browser (Internet explorer, Chrome, Opera, Safari, etc) and type www.rcdc.gov.bt in the url bar. The RCDC web page below will be displayed. Best supported browser is google chrome with Screen resolution greater than 1024x768 pixels for NEWARSIS.
1.1 User Registration
1. To register in NEWARS, click on NEWARS dropdown menu and click on User Registration menu item.
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2. User registration form will be displayed as shown below.
3. Fill the user registration information as required by the system (Note: your username should be unique for the system and your mobile number should have eight digits and not already registered for NEWARS).
1.4. Click submits registration details button as shown in the Figure …...
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2. Change Password/Mobile No/Centre Change
1. Click on NEWARS menu dropdown and click on Password/Mobile No/Center Change menu item to change password, mobile number and health center.
2. Password Reset, Mobile No Change and Centre Change page will be displayed
3. To reset password, type your username in username textbox under password Reset if you are a registered user. Mobile number verification against
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National Early Warning, Alert & Response Surveillance
your username is necessary to reset password. The new password will be sent to your registered mobile number and email.
4. Click Reset Password button to submit.
5. To change your mobile number, you need to type your username and existing registered mobile number followed by new one that you want to replace with.
6. Click Change Mobile No button to submit.
7. To change health center, type your username and then select name of health center that you are registered from drop down list, followed by the new health center you want to transfer your user details to and then mention reason for change of health center for verification and approval by the system manager.
8. Click Submit Center Change Request button to submit
3. Web Reporting
To report weekly, immediate and event through web,
1. Scroll down the web page and look for System User Login Form.
2. Click on Select System and select RCDC Surveillance.
3. Type your username and password and
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click on login button to access RCDC Surveillance System Dashboard.
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6. Click on User Profile menu to change designation, email ID, mobile number, and register second mobile number.
7. Users can also change password, send health center change request from Dashboard using button Change Password and Change Center respectively.
Online disease reporting
1. To access NEWAR System, click on National Early Warning, Alert and Response Surveillance Information System and you will be directed to National Early Warning, Alert and Response Surveillance Information System dash board where indicators for Weekly, Immediate and Event Report is displayed.
3.1. Submit Weekly Report:
1. Click on Weekly manual the left-hand side of Dashboard.
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2. Weekly report management page will be displayed. This page will have record of recent/previously submitted weekly reports.
3. To add weekly report, Click on Add Weekly Report button at the top right-hand side of the Weekly Report Manager. Weekly Report page/form for submitting report will be displayed.
4. Select Year and Week you of your report. Reporter name and health center and unit will automatically selected by the system.
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5. Type number of cases and deaths under specific age group against disease or syndrome.
6. Click Submit Weekly Report button. Alert box on the browser will display with message “report submitted successfully” or “Report Submission Failed”. If report submission fail, correct the report and submit again.
7. To Edit Weekly Report, go back to weekly report manager page and click on Update button at end (under action)against the week and year you want to edit. Weekly report edit form will be displayed.
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Make changes in number of cases and deaths under specific age group against disease or syndrome if there is any and click on Update Weekly Report button. Alert box on the browser will be displayed with message either “report update successfully” or “Report update Failed”. If report submission fails, correct and submit again.
8. If there is no case or death for the epidemiology week, Select Year and Week and click on Submit Weekly Report button. The report will be saved as ZERO report.
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3.2. Immediate Report:
1. Click on Immediate menu item at the left-hand side of Dashboard.
2. Immediate Report Manager page will be displayed. This page will have records of previous/recent immediate reports submitted.
3. To add immediate report, Click on Add Immediate Report button at the top right-hand side of the Immediate Report Manager page.
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4. A form for submitting Immediate Report will display.
5. Type in or select the case date from calendar box. Tick/check in checkbox against the immediate disease or syndrome to be reported.
6. Enter number of cases and deaths under specific age group against disease of syndrome.
7. Click on Submit Immediate Report button. Alert box on the browser will display with message either “report submitted successfully” or “Report Submission Failed”. If report submission fail, correct the report and submit again.
8. To Edit Immediate Report, go back to Immediate Report Manager page. Click on Update button under Action row against the date you want to edit. Form for editing the report will be displayed. Make any necessary changes and click on Update Immediate Report button. Alert box on the browser will be displayed with message either “report update successfully” or “Report update Failed”. If report submission fail, correct and submit again.
//edited till here
9. To submit case investigation form (CIF), go to Immediate Report Manager (immediate report dashboard) and click Manage Button under CIF menu against specific disease/syndrome for that particular date. CIF Manager Page will be displayed.
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10. Enter patient information and click on Save Patient Info button. Click Update button under Action menu in CIF Manager Page to edit existing Patient info OR to fill up Investigation datail.
11. Enter all information required in CIF and click Update button under each sub-heading/information section.
12. Click Upload CIF button at top right-hand side to upload CIF files (pdf/Doc/xls/jpg/png/gif) if online CIF information could be not submitted.
Add Immediate Report Form
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3.3. Event Report
1. Click Event menu item at the left side of Dashboard.
2. Event Report Manager (Event Report Dashboard) page will be displayed. This page will have record of previous/recent event reports submitted.
3. To submit event report, Click on Add Event Report button at the top right-hand side of the Event Report Manager page. Event reporting page/form will be displayed.
4. Enter information as required.
5. Click on Report Event button to submit event report. Alert box on the browser will be displayed with the message “report submitted successfully” or “Report Submission Failed”. If report submission fail, correct and submit again.
6. To update case/death number on daily
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basis, click on update button button under case/death menu in Event Report Manager page against the event you want to update the case/death. Update Event Case Death page will be displayed. Click on Add Case/Death button at top right-hand side. A form will be displayed where you need to fill date, case and death detail. Click on Submit Case/Death button. Case/death update must be donetill event is declared over.
7. Click on Manage button under Linelist menu against the event at Event Report Manager page to submit line-list.
8. Click on Manage/Add button under Response(Res) menu against the event at Event Report Manager page to submit event response reports
9. To add response, Select appropriate response from response dropdown list. Select appropriate response type (Preliminary/Final report) to be submitted. Add brief summary report of event and upload event response report and click on Submit Response button to submit to complete response for an event.
10. After response report submission is completed, Event Response Manager Page will be displayed and under Gallery, click on Add button to upload photo of event. Report
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National Early Warning, Alert & Response Surveillance
can be view, update or delete by clicking appropriate button display in the Event Response Manger page. Second response can be added by clicking on Add Response button at top right-hand side of the response manager page.
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4. Data export
1. Click Report menu at the left side of Dashboard.
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2. Report Manager page will be displayed.
3. Click appropriate button to view weekly, immediate and event indicators and reports
4. Click Export button to export data in excel file.
Figure 15: Report Manager Dashboard
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National Early Warning, Alert & Response Surveillance
5. SMS System
Unlike web system, SMS works based on keywords (codes) and it is important to know and remember all keywords. Mobile SMS options can be used where the is no internet connectivity at health facility.
5.1 Understanding SMS keywords.To know all SMS keywords for NEWARS system, type “Newars” and send to SMS hotline number 7712399. User will receive SMS reply with all help keywords used in NEWARS for SMS application.
5.2. User Registration
To send user registration request, Compose the message using the format:
REGUSER<singlespace>preferred_username*FullName*Designation*Center Name and send to 7712399.
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First SMS reply will be received from system stating registration request has been received.
Second SMS will be received stating approval of registration with username and system generated password (below is an SMS reply example).
To check user registration details, type CHKUSER on message box and send it to SMS hotline number. Details of registration will be received (below is an SMS reply example).
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National Early Warning, Alert & Response Surveillance
5.3. Adding Second Mobile Number
To register second mobile number, Compose the message using the format:
ADDMOBILE<single space>SECOND_MOBILE_Number and sent it to 7712399. SMS reply will be received stating mobile 2 has been added in the system (below is an SMS reply example). After that reporting can be done from both mobile number.
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5.4. Change Mobile Number
to change mobile number, Compose the message using the format:
CHGMOBILE<single space>New_Mobile_Number and send to 7712399. SMS reply will be received stating mobile number submitted to the system has been changed (below is an SMS reply example). Once system changes your previously registered mobile number to new mobile number, system will not accept any reports from previously registered mobile number.
5.5. Change Password/Password Reset
To change or reset password, Compose the message using the format:
CHGPASSWORD<single space>New_Password and sent to 7712399. SMS reply will be received stating password has been changed with your username. [this is useful in case of forgotten username or password] (below is an SMS reply example).
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National Early Warning, Alert & Response Surveillance
5.6. Request Health Center Change
To request health center change, compose the messageusing the format:
CHGCENTER<single space>New_Center_Name and send to 77123999.
First SMS reply will be received from system stating change center request has been received. User registration details will still under old health center and place reports will be placed to hold health center unless it is approved.
Second SMS will be received stating request to change center has been approved by the system administrator (below is an SMS reply example). After this SMS, system will place report to changed health center as your user registration details are transferred in the system.
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5.7. Check Dates for Epidemiological Week Number
To check dates for epidemiological week number, compose message in followingformat,
CHKWEEK<single space>Week_Number.
SMS reply will be received with dates of given epidemiological week of the current year (below is an SMS reply example).
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National Early Warning, Alert & Response Surveillance
5.8. Check Reporting Deadline
To check reporting deadlines, compose message with keywordCHKDEADLINE. SMS reply will be received with deadline dates for weekly, immediate and event (below is an SMS reply).
5.9. Check for NEWARS Support Team
Compose message with keyword CHKSUPPORT and send to7712399. SMS reply will be received with the names of surveillance officer and IT focal persons at RCDC (below is an SMS reply).
National Early Warning, Alert & Response Surveillance
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5.10. Check Weekly Disease List
To check weekly reportable diseases/syndromes, compose sms with keyword HLPWKDID and send to 7712399. SMS reply will be received disease code with disease and syndromes abbreviation (below is an SMS reply).
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5.11. Submit Weekly Report
Compose the SMS report using the format:
WK<single space>WeekNo.Year (YY)*WKDID-AG.Case.Death,AG.Case.Death*WKDID-AG.Case.Death and send it to 7712399.
SMS reply will be received acknowledging successfully submission of the report (below is an example of SMS reply).
5.12. Submit Zero Report
To submit Zero report, compose the SMS report using the format:
ZERO<single space>WeekNo.Year(YY) and send to 7712399.
SMS reply will be received acknowledging successfully submission of zero report (below is an example of SMS reply).
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5.13. Check Immediate Reporting Disease/syndromes List
Compose SMS with keywordHLPIMDID and send to7712399 to check immediate reporting disease/ syndrome list.
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National Early Warning, Alert & Response Surveillance
5.14. Submit Immediate Report
Compose the SMS report using the format :
IM<single space>DD.MM.YY*IMDID-AG.Case.Death ,AG.Case .Death* IMDID-AG.Case .Death,AG.Case.Death and send it to7712399.
SMS reply will be received acknowledging successfully submission of the report (below is an example of SMS reply).
5.17. Submit Event Report
To submit event report, compose the SMS report using the format:
EVT<single space>DD.MM.YY*Event Name*Event Location*No. of Population Affected(Number) and send to 77123999.
SMS reply will be received acknowledging successfully submission of the report (below is an example of SMS reply).
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5.18. Update Event Report Cases/Deaths
Compose the SMS report using the Format:
EVTUPDATE<single space>DD.MM.YY*EventID-AdditionalCase.AdditionalDeath and send to 77123999.
SMS reply will be received acknowledging successfully submission of the report (below is an example of SMS reply).
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National Early Warning, Alert & Response Surveillance
5.19. Delete Weekly Report
Compose the SMS report using the Format:
DELWK<single space>Week No. Year(YY) and send 77123999. SMS reply will be received acknowledging successfully submission of the weekly report (below is an example of SMS reply).
5.20. Delete Immediate Report
Compose the SMS report using the format:
DELIM<Single Space>DD.MM.YY(Case Date)and send to 77123999. Note: All the reports submitted for that particular case date will be deleted from the system.
SMS reply will be received acknowledging successfully deletion of the immediate report (below is an example of SMS reply).
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Important Points for SMS reporting:
1. You should not be repeating DiseaseId in a weekly/Immediate report
2. You should not be repeating ageGroupId within a diseaseId for weekly/Immediate report
3. There is always *(asterisk) infront of Disease Id and –(Hyphen) after the Disease ID
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References1. National Early Warning, Alert & Response
Surveillance, 1st edition 2014, Public Health Laboratory, DoPH, Ministry of Health, Bhutan 2014
2. National Immunization Policy and Strategic Guidelines, Vaccine Preventable Disease Program DoPH, Ministry of Health, Bhutan 2011
3. Disease outbreak investigation and Control manual, 1st ed. 2015, DoPH, 0oH, Bhutan
4. WHO communicable diseases surveillance and response system, guide for monitoring and evaluating WHO/CDS/EPR/LYO/2006.2
1. WHO recommended strategies for the prevention and control of communicable diseases, WHO/CDS/CPE/SMT/2001.13
2. CDC; Framework for Evaluating Public Health Surveillance Systems for Early Detection of Outbreaks Vol. 53 / RR-5,MMWR, May 7, 2004
3. Operational manual for district surveillance unit, Directorate General of Health Services, Ministry of Health and Family Welfare,New Delhi.
4. Communicable diseases surveillance, Centre for Health protection, Hong Kong, Version 2.
5. Management Protocol Manual, Communicable Disease Control Unit, Public Health, Manitoba Health. 2006*
6. Park, K. Textbook of Preventive & Social Medicine, 14th edition, M/s Banaras Bhanot, 1994.
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7. LAO EWARN manual, year 2012 by NCLE and WHO
8. A guideline to establishing Event Based Surveillance, World Health Organization Western Pacific Region (2008), ISBN 978 92 9061 321 3
9. International Health Regulation, World Health Organization (2005), World Health Assembly 58, Geneva
10. Guideline for Evaluating Surveillance System, Bureau of Epidemiology, Ministry of health, Thailand; ISBN 974 297 264 8
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National Early Warning, Alert & Response Surveillance
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8
Acu
te R
espi
ra-
tory
Infe
ctio
nC
ase
Dea
th
10D
engu
e Fe
ver
Cas
e
Dea
th
National Early Warning, Alert & Response Surveillance
Page 110 of 144
11
Mum
psC
ase
Dea
th
13
Feve
r with
R
ash
Cas
e
Dea
th
14
Food
Poi
soni
ngC
ase
Dea
th
21
Typh
oid/
Par
aty-
phoi
d Fe
ver
Cas
e
Dea
th
23
Sev
ere
Acu
te
Res
pira
tory
In
fect
ion
Cas
e
Dea
th
24
Ric
ketts
iose
sC
ase
Dea
th
Page 111 of 144
National Early Warning, Alert & Response Surveillance
Ann
exur
e 2:
Imm
edia
tely
Not
ifiab
le D
isea
ses/
Syn
drom
es
Dis
-ea
se
ID
Dis
ease
/Syn
-dr
ome
Type
0-29
D
ays
1-11
M
onth
s1-
4 Y
rs5-
9 Y
rs10
-14
Yrs
15-1
9 Y
rs20
-24
Yrs
25-4
9 Y
rs50
-64
Yrs
65 Y
rs
+M
FM
FM
FM
FM
FM
FM
FM
FM
FM
F
100
Ant
hrax
Cas
e
Dea
th
101
Acu
te F
lacc
id
Par
alys
isC
ase
Dea
th
102
Acu
te H
ae-
mor
rhag
ic
Feve
r
Cas
e
Dea
th
103
Avia
n In
flu-
enza
Cas
e
Dea
th
104
Bac
teria
l M
enin
gitis
Cas
e
Dea
th
National Early Warning, Alert & Response Surveillance
Page 112 of 144
105
Cho
lera
Cas
e
D
eath
106
Mal
aria
Cas
e
D
eath
107
Mea
sles
/Ru-
bella
Cas
e
D
eath
108
Per
tuss
isC
ase
Dea
th
109
Con
geni
tal
Rub
ella
S
yndr
ome
Cas
e
Dea
th
110
Hum
an
Rab
ies
Cas
e
D
eath
111
Sev
ere
Den
gue
Cas
e
D
eath
112
Neo
nata
l Te
tanu
sC
ase
Dea
th
113
Dip
hthe
riaC
ase
Dea
th
114
Acu
te E
n-ce
phal
itis
Syn
drom
e
Cas
e
Dea
th
Page 113 of 144
National Early Warning, Alert & Response Surveillance
Ann
exur
e 3.
Gen
eral
Cas
e In
vest
igat
ion
form
Gen
eral
Cas
e In
vest
igat
ion
form
for i
mm
edia
tely
repo
rtab
le d
isea
ses
Plea
se t
ick
agai
nst t
o di
seas
es th
at y
ou w
ant t
o re
port
: D
isea
se th
at d
oes
not h
ave
spec
ific
case
inve
s-tig
atio
n fo
rm :
Plea
se ti
ck C
ase
Stat
us*
Con
firm
ed, S
uspe
cted
, Ep
i-lin
ked
Non
-cas
e U
nkno
wn
Bas
ic In
form
atio
n of
pat
ient
Nam
eA
geS
ex (
M/F
)
Occ
upat
ion
Mob
ile #
Res
iden
ce
Urb
an/R
ural
Pre
sent
A
ddre
ssVi
llage
Geo
gD
istri
ct
If ch
ild is
≤ 5
yea
rs g
et th
e va
cci-
natio
n de
tails
National Early Warning, Alert & Response Surveillance
Page 114 of 144
Clin
ical
info
rmat
ion
(ple
ase
tick
agai
nst t
hose
are
pre
sent
)
Sig
n an
d S
ympt
om
(tick
)
Dat
e of
O
nset
Sig
n an
d S
ympt
om (t
ick)
Dat
e of
Ons
et
Feve
r now
(>
) 38C
Pet
echa
ie/e
chym
ose
Hea
dach
e
Any
ble
edin
g di
sord
ers
Ski
n R
ashe
s
Alte
red
cons
ciou
snes
s
Mya
lgia
C
onvu
lsio
n
Vom
iting
O
ther
sym
ptom
s S
peci
fy
Tem
pera
ture
Pul
sB
PG
CS
Gen
eral
con
ditio
n (s
peci
fy)
Page 115 of 144
National Early Warning, Alert & Response Surveillance
Patie
nt S
tatu
s H
ospi
taliz
ed c
ase
Hos
pita
l Adm
issi
onD
oAD
oD
Sta
tus
Rec
ov-
ered
still
sic
kD
ied
If re
ferr
ed: N
ame
of H
ospi
tal
Dia
gnos
is
Epid
emio
logi
cal i
nfor
mat
ion
H/o
sim
ilar i
llnes
s in
fam
ilyYe
sN
oU
nkno
wn
Trav
el H
isto
ry (3
-21
days
bef
ore
the
onse
t of s
ympt
oms)
Yes
No
Unk
now
n
Trav
el d
ate
from
Trav
el p
lace
His
tory
of c
onta
ct w
ith s
ick
anim
als
Yes
No
Unk
now
n
Evi
denc
e o
f dis
ease
like
rabi
es/
anth
rax/
bird
-flu
in a
nim
alYe
sN
oU
nkno
wn
Any
his
tory
of d
isea
ses
outb
reak
in
the
com
mun
ityYe
sN
oU
nkno
wn
Nam
e of
out
brea
k:
National Early Warning, Alert & Response Surveillance
Page 116 of 144
Labo
rato
ry In
form
atio
n at
Loc
al le
vel
Labo
rato
ry
test
Res
ults
Rem
arks
Low
est w
hite
bl
ood
cells
Pla
tele
ts
coun
t
Blo
od U
rea
Cre
atin
ine
Rap
id te
st
resu
lt S
peci
fy
Blo
od C
/s
CS
F cu
lture
Any
oth
er te
st
done
Page 117 of 144
National Early Warning, Alert & Response Surveillance
Sam
ples
tran
sfer
to R
CD
C f
or :
Nam
e of
H
ealth
Cen
ter
Nam
e of
in
vest
igat
or
Con
tact
# o
f Inv
estig
ator
Dat
e o
f in
vest
igat
ion
National Early Warning, Alert & Response Surveillance
Page 118 of 144
Annexure 4. MR Case investigation form
Page 119 of 144
National Early Warning, Alert & Response Surveillance
National Early Warning, Alert & Response Surveillance
Page 120 of 144
Ann
exur
e 5.
CR
S C
ase
inve
stig
atio
n fo
rm
Cas
e ID
: Reg
ion:
Dis
tric
t:
Dat
e of
not
ifica
tion:
___
/___
/___
D
ate
of in
vest
igat
ion:
___
/___
/___
Dat
e of
repo
rtin
g: _
__ /_
__ /_
__
A. I
dent
ifica
tion
Nam
e of
the
child
: ___
____
____
____
____
____
____
____
____
_ Se
x: M
ale
Fem
ale
Dat
e of
birt
h: _
__ /_
__ /_
__ if
not
ava
ilabl
e –
age
in m
onth
s___
__ A
ddre
ss:_
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Plac
e in
fant
del
iver
ed: _
____
____
____
____
____
____
_N
ame
of m
othe
r:__
____
____
____
____
____
____
____
__
B. C
linic
al s
igns
and
sym
ptom
s
Ges
tatio
nal a
ge (w
eeks
) at b
irth:
____
__ B
irth
wei
ght (
gram
s): _
____
____
____
____
____
____
_
Page 121 of 144
National Early Warning, Alert & Response Surveillance
Gro
up A
(ple
ase
com
plet
e al
l)G
roup
B (p
leas
e co
mpl
ete
all)
Con
geni
tal h
eart
dis
ease
: Ye
s N
o U
nkno
wn
Purp
ura:
Ye
s N
o U
nkno
wn
If y
es, s
peci
fy d
efec
t:___
____
____
____
____
____
___
Mic
roce
phal
y:
Ye
s N
o U
nkno
wn
Cat
arac
ts:
Yes
No
Unk
now
nM
enin
goen
ceph
aliti
s Y
es N
o U
nkno
wn
Con
geni
tal g
lauc
oma:
Yes
No
Unk
now
nJa
undi
ce:
Yes
No
Unk
now
n
Pigm
enta
ry re
tinop
athy
: Ye
s N
o U
nkno
wn
Sple
nom
egal
y:
Ye
s N
o U
nkno
wn
Hea
ring
impa
irmen
t:
Ye
s N
o U
nkno
wn
Dev
elop
men
tal d
elay
: Ye
s N
o U
nkno
wn
R
adio
luce
nt b
one
dise
ase:
Yes
No
Unk
now
n
Oth
er a
bnor
mal
ities
: Yes
No
If y
es p
leas
e de
scrib
e:__
____
____
____
____
____
____
____
____
____
Nam
e of
phy
sici
an w
ho e
xam
ined
infa
nt:_
____
____
____
____
____
____
____
____
____
____
____
____
__
City
/tow
n/vi
llage
:___
____
____
____
____
____
____
____
____
____
____
Tel
epho
ne:_
____
____
____
____
____
__
Pres
ent s
tatu
s of
infa
nt: A
live
Dea
d
If de
ad, c
ause
of d
eath
: ___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
National Early Warning, Alert & Response Surveillance
Page 122 of 144
Aut
opsy
con
duct
ed: Y
es N
o U
nkno
wn
Aut
opsy
find
ings
:___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Aut
opsy
dat
e:__
___/
____
/___
____
C. M
ater
nal h
isto
ry/A
nten
atal
car
e
Num
ber o
f pre
viou
s pr
egna
ncie
s:
Mot
her’s
age
(yea
rs):
Vacc
inat
ed a
gain
st ru
bella
: Yes
No
Unk
now
n If
yes
, giv
e da
te: _
__/_
__/_
__
Rub
ella
like
illn
ess
durin
g pr
egna
ncy:
Yes
No
Unk
now
n If
yes
, Mon
th o
f pre
gnan
cy:_
____
____
____
__
Mac
ulop
apul
ar ra
sh: Y
es N
o U
nkno
wn
If y
es, d
ate
of o
nset
___/
___/
___
Lym
ph n
odes
sw
olle
n: Y
es N
o U
nkno
wn
If y
es, d
ate
of o
nset
___/
___/
___
Art
hral
gia/
arth
ritis
: Yes
No
Unk
now
n If
yes
, dat
e of
ons
et__
_/__
_/__
_
Oth
er c
ompl
icat
ions
Yes
No
Unk
now
n If
yes
, dat
e of
ons
et__
_/__
_/__
_
Was
rube
lla la
bora
tory
-con
firm
ed in
the
mot
her Y
es N
o U
nkno
wn
If ye
s, w
hen
(dat
e): _
__/_
__/_
__
Page 123 of 144
National Early Warning, Alert & Response Surveillance
Was
the
mot
her e
xpos
ed d
urin
g pr
egna
ncy
to p
erso
n of
any
age
with
mac
ulop
apul
ar (e
.g. n
ot v
esic
ular
) ra
sh
illne
ss w
ith fe
ver Y
es N
o U
nkno
wn
If y
es, w
hen
(dat
e): _
__/_
__/_
__
Mon
th o
f pre
gnan
cy:_
____
____
____
____
____
____
____
__D
escr
ibe
whe
re:_
____
____
____
____
____
____
____
____
__
Did
the
mot
her t
rave
l dur
ing
preg
nanc
y: Y
es N
o U
nkno
wn
If ye
s, w
hen
(dat
e): _
__/_
__/_
__
Mon
th o
f pre
gnan
cy:_
____
____
____
____
____
____
____
__ D
escr
ibe
whe
re:_
____
____
____
____
____
_
D. I
nfan
t/chi
ld la
bora
tory
inve
stig
atio
ns
Firs
t spe
cim
en:
Spec
imen
col
lect
ed: Y
es N
o U
nkno
wn
Type
of s
peci
men
: Ser
um T
hroa
t sw
ab U
rine
Oth
erD
ate
of s
peci
men
col
lect
ion:
___
/___
/___
Dat
e sp
ecim
en s
ent:
___/
___/
___
Dat
e sp
ecim
en re
ceiv
ed in
Lab
: ___
__/_
___/
____
_
National Early Warning, Alert & Response Surveillance
Page 124 of 144
Rub
ella
IgM
: Not
test
ed P
ositi
ve N
egat
ive
In p
roce
ss I
ncon
clus
ive
Rub
ella
IgG
: Not
requ
ired
Not
test
ed P
ositi
ve N
egat
ive
In p
roce
ss I
ncon
clus
ive
Seco
nd s
peci
men
:Sp
ecim
en c
olle
cted
: Yes
No
Unk
now
n N
ot re
quire
dTy
pe o
f spe
cim
en: S
erum
Thr
oat s
wab
Urin
e C
ereb
rosp
inal
flui
d O
ther
Dat
e of
spe
cim
en c
olle
ctio
n: _
__/_
__/_
__ D
ate
spec
imen
sen
t: __
_/__
_/__
_D
ate
spec
imen
rece
ived
in L
ab: _
____
/___
_/__
___
Rub
ella
IgM
: Not
requ
ired
Not
test
ed P
ositi
ve N
egat
ive
In p
roce
ss I
ncon
clus
ive
Rub
ella
IgG
: Not
requ
ired
Not
test
ed P
ositi
ve N
egat
ive
In p
roce
ss I
ncon
clus
ive
Sust
aine
d Ig
G le
vel*:
IgG
not
test
ed Y
es N
o In
pro
cess
(*su
stai
ned
IgG
leve
l on
at le
ast 2
occ
asio
ns b
etw
een
6 an
d 12
mon
ths
of a
ge)
Rub
ella
viru
s is
olat
ion:
Not
test
ed P
ositi
ve N
egat
ive
In p
roce
ss
Rub
ella
PC
R: N
ot d
one
Pos
itive
Neg
ativ
e In
pro
cess
Gen
otyp
e___
____
Page 125 of 144
National Early Warning, Alert & Response Surveillance
Dat
e of
labo
rato
ry re
sult
(firs
t val
idat
ed re
sult)
repo
rted
: ___
_/__
__/_
___
E. F
inal
cla
ssifi
catio
n
CR
S D
isca
rded
If d
isca
rded
, ple
ase
spec
ify:_
____
____
____
____
____
____
____
____
____
____
_
Cas
e cl
assi
ficat
ion
as L
abor
ator
y-co
nfirm
ed C
linic
al
Cla
ssifi
catio
n by
orig
in: E
ndem
ic I
mpo
rted
Im
port
-rel
ated
Unk
now
n
Dat
e of
fina
l cla
ssifi
catio
n: _
___/
____
/___
_
Inve
stig
ator
:___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
National Early Warning, Alert & Response Surveillance
Page 126 of 144
Ann
exur
e 6:
Cas
e In
vest
igat
ion
Form
for D
ipht
heria
/Per
tuss
is
Cas
e id
entifi
catio
n nu
mbe
r:
1. R
epor
ting
inve
stig
atio
n in
form
atio
n
Dat
e of
cas
e re
port
ed: _
/_/_
Rep
orte
d by
:
Title
/des
igna
tion:
Dat
e of
cas
e in
vest
igat
ed: _
/_/_
Cas
e in
vest
igat
ed b
y:Ti
tle/d
esig
natio
n:
Dat
e of
cas
e ve
rified
: _/_
/_Ve
rified
by:
Title
/des
igna
tion:
Rep
ortin
g he
alth
faci
lity:
2. P
erso
nal i
nfor
mat
ion:
Patie
nt's
nam
e:N
atio
nalit
y:N
atio
nal
Non
-nat
iona
l
Sex:
Mal
e Fe
mal
eD
ate
of b
irth:
_/_
/_A
ge: Y
ears
___M
onth
__
Fath
er's
nam
e:M
othe
r's n
ame:
Page 127 of 144
National Early Warning, Alert & Response Surveillance
Pres
ent a
ddre
ss: V
illag
e/ci
ty
Gew
og
Dis
t:
Chi
ld b
elon
gs to
mig
rato
ry fa
mily
/com
mun
ity: Y
es N
o U
nkno
wn
If ye
s, s
peci
fy: M
igra
tion
Nom
ad
Con
stru
ctio
n si
te O
ther
s, s
peci
fy
3. H
ospi
taliz
atio
n: Y
es
No
If ye
s, n
ame
of h
ospi
tal:
Dat
e of
adm
issi
on: _
/_/_
Dat
e of
dis
char
ge: _
/_/_
4. V
acci
natio
n st
atus
: Any
vac
cine
rece
ived
: Ye
s N
o U
nkno
wn
If re
ceiv
ed, e
ncirc
le v
acci
nes
rece
ived
irre
spec
tive
of a
ge w
hen
they
wer
e re
ceiv
ed
At b
irth
6 w
eeks
10 w
eeks
14 w
eeks
9 mon
ths
24 m
onth
s6
year
s
OPV
0O
PV1
OPV
2O
PV3
MM
R1
MM
R2
Td b
oost
er
BC
GPe
nta1
Pent
a2Pe
nta3
D
T
National Early Warning, Alert & Response Surveillance
Page 128 of 144
Hep
B0
(birt
h do
se)
IPV
O
PV b
oost
er
Sour
ce o
f vac
cina
tion
stat
us: b
y ca
rd/h
isto
ry__
____
____
____
____
____
___
Dat
e of
last
dos
e of
vac
cine
: For
dip
hthe
ria (T
d, P
enta
vale
nt, D
T), F
or P
ertu
ssis
(Pen
tava
lent
): _/
_/_
In c
ase
of N
eona
tal t
etan
us -
mot
her's
vac
cina
tion
hist
ory
TT (T
d):1
2 B
oost
er U
nkno
wn
Dat
e of
last
dos
e of
Td:
_/_
/_
5. C
linic
al s
ympt
oms:
Dur
atio
n of
illn
ess
in d
ays:
Dip
hthe
ria
Dat
e of
ons
et o
f fev
er w
ith s
ore
thro
at: _
/_/_
Sore
thro
at: Y
es N
o
Feve
r: Y
es N
oG
reyi
sh w
hite
adh
eren
t mem
bran
e in
thro
at: Y
es N
o
Page 129 of 144
National Early Warning, Alert & Response Surveillance
Red
ness
of t
onsi
ls: Y
es
No
Hoa
rsen
ess
of v
oice
: Ye
s N
o
Diffi
culty
in s
wal
low
ing:
Yes
No
Bul
l nec
k: Y
es N
o
Diffi
culty
in b
reat
hing
: Yes
No
Pert
ussi
s
Cou
gh m
ore
than
2 w
eeks
: Yes
No
Paro
xysm
s:Ye
s N
o
Cou
gh le
adin
g to
vom
iting
: Yes
No
Who
op: Y
es N
o
Cya
nosi
s: Y
es N
oH
isto
ry o
f act
ive
TB/o
ther
chr
onic
UR
TI: Y
es N
o
Apn
oea:
Yes
No
Spec
ialis
t phy
sici
an s
tron
gly
sugg
est p
ertu
ssis
:Yes
No
National Early Warning, Alert & Response Surveillance
Page 130 of 144
Ann
exur
e 7.
Cas
e In
vest
igat
ion
Form
for N
eona
tal T
etan
us
Neo
nata
l Tet
anus
Chi
ld n
orm
al in
0-2
day
s:Ye
s N
oO
nset
3-2
8 da
ys
of a
ge:Y
es N
o
Inab
ility
to s
uck
and
cry:
Yes
No
Stiff
ness
: Yes
No
Spas
m/s
eizu
re: Y
es N
oIf
yes,
pre
cipi
tate
d by
stim
uli:
Yes
No
Del
iver
y: In
stitu
tiona
l hom
e ot
hers
, spe
cify
:
If ho
me
deliv
ery,
birt
h at
tend
ed b
y:
Any
sub
stan
ce a
pplie
d on
cor
d: Y
es N
oIf
yes,
spe
cify
:
Ence
phal
itic
Feve
r: Y
es N
oSe
izur
e:Ye
s N
o
Page 131 of 144
National Early Warning, Alert & Response Surveillance
Para
lysi
s: Y
es N
oN
eck
rigid
ity:
Yes
No
Unk
now
n
Hea
dach
e:Ye
s N
o U
nkno
wn
Unc
onsc
ious
-ne
ss:Y
es N
o
Unk
now
n
Cha
nge
in m
enta
l sta
tus:
Yes
No
Any
oth
er,
spec
ify:
6. T
reat
men
t his
tory
Ant
ibio
tic s
tart
ed b
efor
e sa
mpl
e co
llect
ion:
Yes
No
Unk
now
n
If ye
s, P
enic
illin
Azi
thro
myc
in E
ryth
rom
ycin
Cla
rithr
omyc
in C
otrim
oxaz
ole
Cla
rithr
omyc
in T
etra
cycl
ine
Dox
ycyc
line
Am
oxic
illin
Am
pici
llin
Cef
exim
e
Oth
ers,
spe
cify
:
Dip
hthe
ria a
ntito
xin:
Yes
No
Unk
now
n N
ot a
pplic
able
National Early Warning, Alert & Response Surveillance
Page 132 of 144
7. C
onta
ct h
isto
ry
His
tory
of c
onta
ct w
ith la
bora
tory
con
firm
ed c
ase:
Yes
No
If ye
s, c
ase
ID n
o of
labo
rato
ry c
onfir
med
cas
e:
Sim
ilar s
ympt
oms
in o
ther
hou
seho
ld c
onta
cts:
Yes
No
If ye
s, n
o of
cas
es:
Det
ails
:
Sim
ilar s
ympt
oms
in o
ther
nei
ghbo
rhoo
d/w
orkp
lace
/sch
ool c
onta
cts:
Yes
No
If ye
s, n
o of
cas
es:
D
etai
ls:
8. T
rave
l his
tory
: Tra
vel o
f sus
pect
ed c
ase
with
in 2
1 da
ys p
rior t
o on
set (
indi
cate
dat
e an
d pl
ace
of d
ate
line
Plac
e of
vis
it:
Page 133 of 144
National Early Warning, Alert & Response Surveillance
Req
uire
s cr
oss
notifi
catio
n: Y
es N
o
If ye
s, d
ate
of
cros
s no
tifica
tion:
_/
_/_
In c
ase
of n
eona
tal t
etan
us, n
ame
the
plac
e of
del
iver
y:
9. H
isto
ry o
f vis
it to
ano
ther
hea
lth c
ente
r afte
r the
dat
e of
ons
et: Y
es N
o
If ye
s, d
ate
of v
isit:
_/_
/_N
ame
of h
ealth
ce
nter
:
National Early Warning, Alert & Response Surveillance
Page 134 of 144
Ann
exur
e 8.
AFP
Cas
e in
vest
igat
ion
form
1. R
epor
t/Inv
estig
atio
n in
form
atio
n
Nam
e of
inve
stig
ator
____
____
____
_
Dat
e C
ase
Rep
orte
d: _
____
____
____
____
____
Titl
e: _
____
____
____
____
____
____
Dat
e C
ase
Inve
stig
ated
: ___
____
____
____
____
Nam
e of
BH
U/H
ospi
tal:
2. C
ase
Iden
tifica
tion
Cas
e id
entifi
catio
n no
: BH
U --
---/--
---/--
---
Patie
nt’s
nam
e:__
____
____
____
____
____
____
____
____
_ Se
x: M
ale
Fem
ale
Dat
e of
Birt
hday
-----
/-----
/-----
Age
:Yea
r ___
____
Mon
ths_
____
__
Add
ress
to fi
nd th
e ch
ild fo
r fol
low
up
in 6
0 da
ys:_
____
____
____
____
____
____
____
____
____
_
Villa
ge: _
____
____
____
___
Gew
og :
____
____
____
____
_ D
zong
khag
___
____
____
____
_
Perm
anen
t Add
ress
(if d
iffer
ent)_
____
____
____
____
____
____
____
___
Mob
ile N
o:---
------
---
3. H
ospi
taliz
atio
n: Y
es N
o
D
ate
of H
ospi
taliz
atio
n: --
---/--
---/--
---
Nam
e of
the
hosp
ital:
____
____
____
____
____
____
___H
ospi
tal r
egis
trat
ion
num
ber:
____
____
____
__
Page 135 of 144
National Early Warning, Alert & Response Surveillance
4. Im
mun
izat
ion
His
tory
:
Tot
al O
PV d
oses
rece
ived
thro
ugh
rout
ine
EPI:
____
____
__
To
tal O
PV d
oses
rece
ived
thro
ugh
NID
S: _
____
____
____
_
D
ate
of la
st d
oes
of O
PV (r
outin
e):_
____
____
____
____
D
ate
of I
PV --
------
------
------
------
------
------
------
------
---
5. S
igns
and
Sym
ptom
s:
Dat
e of
par
alys
is o
nset
:___
____
____
____
____
__
Num
ber o
f day
s fr
om o
nset
to m
axim
um p
aral
ysis
:___
____
____
____
____
____
____
___
Acu
te F
lacc
id p
aral
ysis
:
Yes
No
Unk
now
n
Flac
cid
para
lysi
s:
Ye
s N
o U
nkno
wn
Any
inje
ctio
ns d
urin
g th
e 30
day
s be
fore
par
alys
is o
nset
: Yes
No
Unk
now
n
Feve
r on
day
of p
aral
ysis
ons
et: Y
es N
o U
nkno
wn
Asy
mm
etric
al P
aral
ysis
: Yes
No
Unk
now
n
Asc
endi
ng p
aral
ysis
: Yes
No
Unk
now
n
Sens
atio
n Lo
ss: Y
es N
o U
nkno
wn
D
esce
ndin
g pa
raly
sis:
Yes
No
Unk
now
n
Site
(s)o
f par
alys
is: r
ight
s ar
ms
/Lef
t arm
/Rig
ht le
gs/ L
eft l
egs/
National Early Warning, Alert & Response Surveillance
Page 136 of 144
6. S
tool
Spe
cim
en C
olle
ctio
n:
D
ate
Col
lect
ed
D
ate
Sent
Labo
rato
ry R
esul
t (ci
rcle
)
Stoo
l 1:_
____
____
___
__
____
____
_ P1
P2
P3
Wild
/Vac
cine
Pe
ndin
g
N
PEV
N
egat
ive
Stoo
l 2:_
____
____
___
__
____
____
_ P1
P2
P3
Wild
/Vac
cine
Pe
ndin
g
N
PEV
N
egat
ive
7. 6
0 D
ay F
ollo
w-u
p Ex
amin
atio
n: Y
es N
o: D
ate:
____
____
____
____
_ If
No,
why
?___
____
____
Die
d? (C
ircle
): Ye
s/N
o
If Ye
s, d
ate:
___
____
____
_ if
died
, cau
se: _
____
____
___
Res
idua
l par
alys
is p
rese
nt: Y
es N
o
Site
of P
aral
ysis
: rig
ht a
rm/le
ft ar
m/ r
ight
leg/
left
leg/
othe
rs (d
escr
ibe)
___
____
____
____
__
Nam
e of
exa
min
er:…
……
……
……
……
…..
Des
igna
tion…
……
…
C
lass
ifica
tion…
……
……
……
..
8. O
utbr
eak
Res
pons
e: D
one:
Yes
/No
Dat
e:__
____
____
_ If
No.
why
?___
____
____
____
If ye
s, d
ate
begu
n: _
____
____
____
Se
tting
: Urb
an/R
ural
Targ
et p
opul
atio
n of
< 5
yrs
: ___
____
____
____
____
____
Num
ber <
5 im
mun
ized
: ___
____
___
Page 137 of 144
National Early Warning, Alert & Response Surveillance
9. F
inal
Cla
ssifi
catio
n
a.C
onfir
med
Pol
io: Y
es N
o.
b.Po
lio c
ompa
tible
: Yes
No
c. If
dis
card
ed, w
hy?
(Tic
k)
If di
scar
ded,
wha
t wer
e th
e fin
al d
iagn
osis
: Gui
llian
Bar
re S
yndr
ome
Tran
sver
se M
yelit
is T
raum
atic
Neu
ritis
O
ther
------
National Early Warning, Alert & Response Surveillance
Page 138 of 144
Ann
exur
e 9.
AES
Cas
e In
vest
igat
ion
Form
Hos
pita
l Reg
istr
atio
n N
o: _
____
____
____
AES
No:
___
____
____
____
____
__ 1.
Inve
stig
atio
n In
form
atio
n:
N
ame
of In
vest
igat
or(s
): __
____
____
____
____
___
Dat
e C
ase
Rep
orte
d: _
____
/___
___
/___
___
D
esig
natio
n: _
____
____
____
____
_D
ate
Cas
e In
vest
igat
ed: _
___
/ ___
_ / _
___
2. C
ase
Iden
tifica
tion:
Pa
tient
’s N
ame:
___
____
____
____
____
Dat
e of
Birt
h: _
___
/ ___
_ /_
__ _
_
A
ge: y
ears
___
mon
ths
___
Sex:
___
Pare
nts
Nam
e :
____
____
____
____
____
____
___
Pe
rman
ent a
ddre
ss:
Mob
ile N
o
:___
____
____
____
___
Vi
llage
:___
____
____
____
_
G
ewog
:___
____
____
____
_R
esid
ing
Add
ress
___
____
____
____
____
____
____
Dzo
ngkh
ag:_
____
____
____
3. H
ospi
taliz
atio
n: Y
es/N
o
D
ate
of H
ospi
taliz
atio
n: _
____
_ / _
____
__ /
____
____
_N
ame
of H
ospi
tal:_
____
____
____
____
____
___
C
linic
al D
iagn
osis
:___
____
____
____
____
____
Out
com
e: R
ecov
ered
com
plet
ely
/Rec
over
ed w
ith d
isab
ility
/ Dea
th/U
nkno
wn
Page 139 of 144
National Early Warning, Alert & Response Surveillance
4. S
ign
and
Sym
ptom
s:D
ate
of o
nset
of s
ympt
oms:
___
____
/___
____
_/__
____
__R
apid
Ons
et: Y
es /
No
/ Unk
now
n
Cha
nge
in m
enta
l sta
tus:
Yes
/ N
o / U
nkno
wn
Hea
dach
e: Y
es /
No
/ Unk
now
n
Seiz
ure:
Yes
/ N
o / U
nkno
wn
Nec
k St
iffne
ss: Y
es /
No
/ Unk
now
n
S
tupo
r: Y
es /
No
/ Unk
now
nPa
resi
s : Y
es /
No
/ Unk
now
n
Trav
el H
isto
ry (2
wee
ks b
efor
e th
e on
set):
Yes
/ N
o / U
nkno
wn
If ye
s, w
here
: ___
____
____
____
____
____
_
5. S
peci
men
s C
olle
ctio
n
Spec
imen
s ty
peD
ate
of s
ampl
e co
llect
edD
ate
of s
ampl
e se
nt to
Lab
(RC
DC
)
Seru
m 1
Seru
m 2
CSF
6. C
ase
Cla
ssifi
catio
n: L
ab c
onfir
med
/ Pr
obab
le /A
ES-o
ther
age
nt /A
ES-u
nkno
wn
National Early Warning, Alert & Response Surveillance
Page 140 of 144
7. S
igna
ture
of i
nves
tigat
or:_
____
____
____
____
____
_Mob
ile N
o:
Cas
e D
efini
tion
of A
ES: C
linic
ally
, a c
ase
of A
cute
Enc
epha
litis
Syn
drom
e (A
ES) i
s de
fined
as
a pe
rson
of
any
age,
in a
ny g
eogr
aphi
cal r
egio
n, a
t any
tim
e of
yea
r with
the
acut
e on
set o
f fev
er a
nd a
cha
nge
in m
enta
l st
atus
(inc
ludi
ng s
ympt
oms
such
as
conf
usio
n, d
isor
ient
atio
n, c
oma,
or i
nabi
lity
to ta
lk) A
ND
/OR
new
ons
et
of s
eizu
res
(Exc
ludi
ng fe
brile
sei
zure
s).
Page 141 of 144
National Early Warning, Alert & Response Surveillance
Annexure 10: Event Reporting Form
EVENT REPORTING FORM
Reporting Site: _________________________Date of Reporting: _________________________
What do you want to report?(Name of event/suspected out-break):*
When did this happen?(Date/Time of Event):*
Where did this happen?(Location of Event):*
Number of people affected:*
Number of people died:*
Mention common signs & symptoms(Clinical Information):
Do you have any other information?:
Reported by _______________ _____________ No Mobile: _____________Dated._____________
National Early Warning, Alert & Response Surveillance
Page 142 of 144
Annexure 11. Preliminary Report of an outbreak Preliminary Report of an outbreak Background
● When was event detected and notified in NEWARS?
● When and where has outbreak occurred?● How did the health center come to know
about the outbreak? (Example: was out-break reported in social media or cluster of cases visited the health center).
Findings● How many cases/death were detected? ● What are the common signs and symp-
toms?● Was the causative agent identified?● What are the possible research hypotheses
on the source of outbreak?● Specify if there was any preceding event
before the outbreak?● Any other information if available.
Action taken● How were patients managed?● Include what public health interventions
were taken such as active case searching, contact tracing, mass vaccination, etc.
● Were any recommendations provided for implementation?
● Were any logistics and supports arranged?● Any other information if available.
Page 143 of 144
National Early Warning, Alert & Response SurveillanceA
nnex
ure
12. D
aily
Out
brea
k R
epor
t
Dat
eTY
PE
0-29
D1-
11M
1-4Y
5-9Y
10-1
4Y15
-19Y
20-2
4Y25
-49Y
50-6
4Y65
+YM
FM
FM
FM
FM
FM
FM
FM
FM
FM
F
C
ase
Dea
th
C
ase
Dea
th
C
ase
Dea
th
C
ase
Dea
th
C
ase
Dea
th
C
ase
Dea
th
C
ase
Dea
th
C
ase
Dea
th
National Early Warning, Alert & Response Surveillance
Page 144 of 144
C
ase
Dea
th
C
ase
Dea
th
C
ase
Dea
th
C
ase
Dea
th
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